bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP404: Cost-Effectiveness of Plaque Echolucency on Ultrasound as a Stroke Risk Stratification Tool in Asymptomatic Carotid Artery Stenosis
Authors: Baradaran Hediyeh , Mushlin Alvin , Kamel Hooman , Gupta Ajay , Pandya Ankur
Published: January 2019

Imaging may play an important role in identifying high-risk plaques in patient with carotid disease who could benefit from surgical revascularization. We sought to evaluate the cost-effectiveness of a decision-making rule based on the ultrasound (US) imaging assessment of plaque echolucency (PE) in patients with asymptomatic carotid stenosis. We developed a decision-analytic model to project lifetime quality-adjusted life years (QALYs) and costs for five stroke prevention strategies: 1) medical therapy only; 2) revascularization if
both
PE and stenosis progression to >90% is present; 3) revascularization only if PE is present; 4) revascularization only if stenosis progression >90% is present; or 5) either PE or stenosis progression is present. Risks of clinical events, costs, and quality-of-life values were estimated based on published sources and the analysis was conducted from a health care system perspective for asymptomatic patients with 70-89% carotid stenosis at presentation. Patients who did not undergo revascularization had the highest stroke events (16.9%) and lowest life-years, while those who underwent revascularization on the basis of either presence of PE on US or progression of carotid stenosis had the lowest stroke events (10.0%) and longest life-years (13.67). The
either
PE or progression-based revascularization group had an incremental cost effectiveness ratio of $43,000/QALY compared with those with revascularization based on having
both
PE and stenosis progression. Plaque echolucency on US can be a cost-effective tool to identify patients with asymptomatic carotid artery stenosis most likely to benefit from carotid endarterectomy.
Abstract WP405: Minimizing Delayed Length of Stay by Utilizing Stroke Transitions of Care Coordination Program
Authors: Zimmerman William D , Grenier Rachel E , Leutbecker Jacqueline A , Geng Xue , Denny M C
Published: January 2019

Introduction:
Delay in discharge of acute stroke patients considered medically ready for discharge increases costs and exposure to nosocomial infections, and is frustrating for patients. We evaluated factors associated with delays in discharge in acute ischemic stroke (AIS) patients in a Transitions of Care Coordination (TOCC) study.

Methods:
From April to July 2018, 29 AIS patients (pts) were randomized to TOCC (n=13) or usual care (n=16) groups. Intracerebral hemorrhage, transient ischemic attack and subarachnoid hemorrhage pts were excluded. In TOCC, a nurse navigator met patient/family, identified barriers to discharge, checked status of diagnostics, attended multi-disciplinary rounds to facilitate rehab referrals, provided stroke education, and coordinated clinic follow-up. Delayed length of stay (dLOS) was defined as the difference between date/time medically ready for discharge and date/time of actual discharge. Demographic variables, NIHSS, mRS and discharge disposition were collected. Continuous variables were analyzed with Wilcoxon rank-sum or Kruskal-Wallis test, and categorical variables with Fisher’s exact test.

Results:
Pts in the TOCC group were older, but other baseline characteristics were well matched (Table 1). dLOS was significantly correlated with NIHSS (

r
s

0.65, p=0.00037. There was a difference in dLOS by insurance type (Medicare 4.05 d vs. Medicaid 17.7 d vs. Commercial 3.0 days, p=0.0250). There was a difference in mean dLOS by discharge disposition (acute rehab 6.5 d, home 1 d, home with home health 1.4 d, subacute rehab 17 d, (and patient death 9 d), p=0.007. There was a difference in distribution of dLOS by distance from home zip code to hospital but no difference was found in the post-hoc analysis. There was no difference in mean dLOS between TOCC and usual care groups (6.5 vs. 4.5 days, p=0.256).

Conclusion:
Higher NIHSS, Medicaid insurance, and discharge to acute rehab were significantly associated with dLOS in AIS patients.
Abstract WP406: New Zealand Hospital Stroke Service Provision: A National Survey
Authors: Ranta Anna , Barber Peter A. , Harwood Matire , Cadilhac Domique , McNaughton Harry , Thompson Stephanie , Fink John , Davis Alan , Gommans John , Girvan Jackie , Abernethy Ginny , Feigin Valery , Wilson Andrew , Douwes Jeroen
Published: January 2019

Introduction:
The REGIONS Care project is a New Zealand (NZ) based nationwide project that aims to capture all stroke patients admitted to NZ hospitals exploring ethic and geographic inequities in stroke care access and patient outcomes. Findings from this study will advise the National Stroke Programme strategy. This project includes an organisational survey to assess current availability of interventions and general management approaches in each hospital.

Methods:
This is a prospective registry based study with up to one year follow-up. Patients are registered into a central database by hospital teams and follow-up is achieved primarily via telephone calls. The outcome data will be adjusted for baseline function and stroke severity among other factors. At this stage the main study is ongoing, but the organisational survey has been completed. Analysis has not yet been finalised. Final and validated results will be presented at the meeting.

Results:
All NZ hospitals were approached and 100% completed the online survey. Preliminary results found that of these hospitals 82% have an acute stroke unit, 86% have a TIA pathway, but only 57% offer rapid access specialist TIA services. 100% offer thrombolysis, 93% use an EMS pre-notification and rapid ED triage system, and 75% an in-hospital ‘code stroke’ alert. 11% offer onsite thrombectomy, and a further 41% access thrombectomy via rapid inter-hospital transfer. 82% offer inter-disciplinary team review within 24 hours of admission and while 100% have access to OT, PT, and SLT, only 27% have access to a psychologist. 100% offer inpatient and 92% community rehabilitation service while only 11% offer early supported discharge programmes. Only 31% of hospitals have a dedicated stroke rehab unit. While 88% routinely provide stroke patient education, only 52% provide individualised stroke care plans at discharge.

Conclusion:
These preliminary results show good access to thrombolysis and multi-disciplinary stroke care. However, improvements are needed in access to thrombectomy, rapid specialist TIA services, early supported discharge, dedicated stroke rehabilitation units, psychologists, and individualised patient care plans. Final and additional results will be presented at the conference.
Abstract WP407: Cohort Study Examining the Association Between Timely Carotid Revascularization and Key Health System Strategies Among Patients With Transient Ischemic Attack and Stroke
Authors: Gocan Sophia , Bourgoin Aline , Shamloul Rany , Sivakumar Brammiya , Dowlatshahi Dar , Stotts Grant
Published: January 2019

International guidelines recommend carotid revascularization within 14 days for symptomatic patients. However, significant delays in care persist, with only 9% of outpatients, and 36% of inpatients in Ontario meeting this target. The purpose of this study was to explore the influence of health system factors on carotid revascularization timelines. We conducted a retrospective chart review of all patients undergoing carotid revascularization (endarterectomy or stenting) at The Ottawa Hospital for a symptomatic TIA/stroke event between 2015 and 2016. The primary outcome was time from TIA/stroke event to carotid revascularization. Health system variables of interest included location of patient presentation (outpatient vs emergency department), event onset to presentation time, event onset to vascular imaging time, and same-day collaboration between key services such as emergency providers, radiology, neurology and surgical teams. We used descriptive statistics and univariate analysis to determine statistically significant differences between groups. A total of 228 records were eligible for inclusion. The median time in days from TIA/stroke event to carotid revascularization was 10 days, with 58% of patients having their procedure within 14 days. Prompt patient presentation to an emergency department was associated with significantly shorter timelines to surgery (7 days, p<.001). Early vascular imaging was strongly correlated with early revascularization (4-5 days, p<.001). In addition, collaboration from two or more care services resulted in enhanced timelines to surgery ranging from 2 to 6.5 days (p<.001-.008). We identified several health system strategies that significantly improved achievement of the best practice recommendation of revascularization within 14 days. This included early patient recognition and presentation to emergency services, which emphasizes the need for public awareness. In addition early vascular imaging was strongly correlated with revascularization timelines, suggesting protocols for rapid investigation of these high risk patients is needed both in Emergency and outpatient settings. Direct, same-day communication between services also promoted expedited revascularization.
Abstract WP408: Time of Day Negatively Impacts Key Acute Stroke Metrics at a Large Academic Center
Authors: Giovanni Brian , Wheelwright Danielle , Stein Laura , Roche Tara , Velickovic Ostojic Lili , Tuhrim Stanley
Published: January 2019

Background/Objective:
Higher volumes in the emergency department (ED) and lower staffing ratios exist during hospital “off hours,” outside of weekday business hours, but the impact of these factors on emergent acute stroke metrics is unknown. As part of a departmental quality improvement project to optimize local policy in the context of new acute stroke treatment guidelines, we sought to assess the impact of time of day on acute stroke code process metrics.

Methods:
We retrospectively analyzed de-identified metrics for 646 stroke codes between January, 2017 and March, 2018. We calculated median times to neuroimaging, tPA administration, and preparation for endovascular therapy (ET) in the endovascular suite based on time of day (“on hours” = weekday business hours vs “off hours” = non-weekday business hours) and patient setting (ED, outside hospital transfer [OSH], inpatient).

Results:
Of all stroke codes, 57 (8.8%) received tPA and 98 (15.1%) received ET. Of these, 44 (77.2%) occurred during “off hours” for tPA and 69 (70.4%) for ET. Median door-to-needle (n=48) and door-to-groin puncture (n=84) time for ED presentations is higher during “off hours” (56 vs 44 min, 111 vs 92 min, respectively). Median door-to-groin puncture is similar for OSH transfers (n=64) regardless of arrival time (56 vs 60 min). For all groups, median time for preparation for ET in the endovascular suite is higher during “off hours” compared to “on hours” (ED 21 vs 19 min, OSH 20 vs 15 min, inpatient 26.5 vs 20 min).

Conclusion:
In our center, acute stroke codes during “off hours” have higher median times to tPA, groin puncture, and preparation for ET. Based on this data we are working to implement earlier activation of the endovascular team at triage for potential large vessel occlusion cases and increase staffing availability during “off hours.”
Abstract WP41: The NeVa Thrombectomy Device: Initial Clinical Experience
Authors: Ribo Marc , Macho Juan , Zamarro Joaquin , Machi Paolo , Hernandez David , Tomasello Alejandro , Blasco Jordi
Published: January 2019

Introduction:
The NeVa (Vesalio) thrombectomy device is a CE approved novel hybrid-cell stent retriever with offset enlarged openings coupled with enhanced expansive radial force and a closed distal end. The device was designed to incorporate and trap resistant emboli inside the device.

Materials and Methods:
Prospective data was collected on the first thirty consecutive patients treated at four stroke centers in two countries with NeVa as first line treatment. Clinical outcome measures included re-perfusion scores after each NeVa pass, device and procedure related complications, 24 hour NIHSS, mRS at discharge and 90 days.

Results:
The mean presenting NIHSS was 16 (IQR 13-20) with mean time from stroke onset of 5.45 hours. Sites of primary occlusion were 10 ICA, 16 M1-MCA, 3 M2-MCA and one basilar. There were five tandem occlusions that required extracranial treatment. Reperfusion outcomes after each NeVa pass; TICI >/= 2b after first pass 63%(19/30), after 1 or 2 passes 83% (25/30), after 1 to 3 passes 90% (27/30). TICI 2c-3 after first pass 47% (14/30), after 1 to 2 passes 57% (17/30), after 1 to 3 passes 60% (18/30). TICI >/= 2b after final NeVa pass 93% (28/30). TICI 2c-3 after final NeVa pass 63% (19/30). There were no device related SAEs and no sICH. Clot material was partially or completely incorporated into the inside of the device after 28 of 40 (70%) passes. The mean 24 hour NIHSS was 7 (IQR 1-11) and the discharge mRS was 0-2 in 40% (12/30) of patients. The 90 day mRS follow up will be completed late August.

Conclusions:
The NeVa device demonstrated a high rate of first pass complete reperfusion effect and a good safety profile in this initial clinical experience.
Abstract WP413: Deconstructing Post-Stroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage
Authors: Reznik Michael E , Drake Jonathan , Margolis Seth A , Moody Scott , Murray Kayleigh , Costa Samantha , Mac Grory Brian C , Yaghi Shadi , Mahta Ali , Wendell Linda C , Thompson Bradford B , Rao Shyam S , Daiello Lori A , Asaad Wael F , Jones Richard N , Furie Karen L
Published: January 2019

Introduction:
Post-stroke delirium is associated with worse outcomes, yet is likely underdiagnosed due to the challenges of disentangling delirium symptoms from underlying neurological deficits. We aimed to determine the prevalence of individual delirium features and the frequency with which they could not be assessed in a cohort of patients with intracerebral hemorrhage (ICH).

Methods:
Consecutive patients admitted with ICH received daily assessments for delirium by an expert clinician, all of which included the Confusion Assessment Method for the ICU (CAM-ICU), Intensive Care Delirium Screening Checklist (ICDSC), a focused bedside cognitive exam, chart review, and nurse interview. We characterized individual symptom prevalence and established delirium diagnoses using DSM-5 criteria, then compared performance of the CAM-ICU and ICDSC with reference-standard diagnosis.

Results:
We performed 257 assessments on 60 patients (mean age 68.0 [SD 18.4], 62% male, median ICH score 1.5 [IQR 1-2]), of whom 55% had delirium. Symptom fluctuation (61% of all assessments), impaired arousal (37%), psychomotor changes (46%), and sleep-wake disturbances (46%) had a high prevalence and were never rated “unable to assess” (UTA), while inattention (36%), disorganized thinking (18%), and disorientation (27%) were also common but were often UTA (32%, 44%, and 43% of assessments, respectively), most frequently due to aphasia (present in 32% of patients). As the ICDSC may be positive without the presence of symptoms that require verbal assessment, it was more accurate (
Sensitivity=
77%,
Specificity=
97%) than the CAM-ICU (
Sensitivity=
41%,
Specificity=
88%) relative to the DSM-5-based reference standard. Allowing non-verbal assessments of attention using visual and auditory stimuli decreased the frequency of UTA assessments to 11%.

Conclusion:
Delirium is common after ICH, but reliance on verbal interaction with patients may confound its assessment and lead to underdiagnosis. The ICDSC’s inclusion of non-verbal features makes it more accurate than the CAM-ICU, but novel tools specifically designed for patients with neurological deficits may be warranted.
Abstract WP414: Stroke Door-to-Needle Target of 30 Minutes or Less: A Single Center Experience
Authors: Fuhrman Susan , Lazarro Marc
Published: January 2019

Background:
Early thrombolysis in acute ischemic stroke is associated with improved outcomes. Current guidelines emphasize early delivery of intravenous (IV) Alteplase (tPA). Additionally, door-to-needle (DTN) time is often a step in the pathway to mechanical thrombectomy. We sought to achieve average DTN time of ≤ 30 minutes in eligible patients.

Methods:
A multidisciplinary team was established. Goal timeframes for the subcomponents of the process were determined. A fishbone diagram was used to identify barriers. Subgroups focused on each category. A tracking feedback tool was used for consistent monthly feedback to all team members. Eligible patients included those meeting GWTG criteria for tPA.

Results:
Four main areas were identified for subgroup intervention: scan interpretation; documentation and communication; location of tPA administration; completion of ancillary tasks prior to tPA. Across 18 months, before and after intervention, quarterly average DTN times were reduced from 56.1 to 26.4 minutes for all patients and 54.6 to 26.1 minutes for eligible patients. Volume of IV tPA delivery increased from 11.5 to 13.75 patients/quarter. Average DTN time ≤ 30 minutes was sustained across 6 months. Symptomatic intracranial hemorrhage rate was unchanged.

Conclusions:
Consistent average DTN times ≤ 30 minutes for acute stroke is possible. A multidisciplinary approach with emphasis on a culture of teamwork and collaboration is essential.
Abstract WP419: Expanding the Use of Teleneurology Network Beyond Acute Stroke: Implications and Significance
Authors: Almallouhi Eyad , Al kasab Sami , Harvey Jillian , Girotra Tarun , Debenham Ellen , Turner Nancy , Holmstedt Christine
Published: January 2019

Background:
The majority of acute stroke patients eveluated through telestroke end up being transferred to the hub for further care; this is largely due to the unavailability of a neurologist on site at spokes. In this study, we investigate the impact of implementing a teleneurology program with an already established telestroke program on the rate of transfers to the hub.

Methods:
This is a retrospective review of the medical records of patients evaluated through the Medical University of South Carolina telestroke network between January 2008 and March 2018. Only patients presenting to telestroke sites that later joined the MUSC teleneurology consultation program were included. Collected data included age, sex, race, NIHSS on arrival, tPA administration, whether patients were seen in the referring hospital before or after establishing the teleneurology program. Chi-square and t-tests were used to compare differences among categorical and continuous variables, respectively. Multivariable logistic regression was used to examine the relationship between presenting with acute stroke after the establishment of teleneurology program and the odds of being transferred to the hub, controlling for patient baseline characteristics.

Results:
A total of 4296 patients were included (2493 patients before the establishment of the teleneurology program and 1803 patients after that). Mean age was 66.4 (SD 14.7) years and 67.8 (SD15.1) in both groups respectively (P=0.002). No difference was found in sex distribution or mean admission NIHSS on admission between both groups. Patients who presented after the establishment of the teleneurology network were less likely to be transferred to the hub (transfer rate 20.2% Vs. 29.4% before telestroke, P<0.001). Results of logistic regression show that the odds ratio for transfer to the hub is 0.573 for patients who presented after the starting the teleneurology program after controlling for baseline characteristics (age, sex, race, admission NIHSS, receiving tPA).

Conclusion:
The implementation of a teleneurology program has allowed stroke patients to receive continuous neurologic care while remaining at spokes. This could reduce the number of unnecessary transfers to a the hub
Abstract WP42: Early Dramatic Improvement on the National Institutes of Health Stroke Scale Predicts Favorable Outcome 90 Days After Thrombectomy in the DEFUSE 3 Study
Authors: Heit Jeremy J , Mlynash Michael , Kemp Stephanie , Lansberg Maarten G , Christiansen Soren , Marks Michael P , Albers Gregory W
Published: January 2019

Introduction:
Thrombectomy in late time windows leads to improved outcomes in patients with ischemic stroke due to large vessel occlusion (LVO). We determined if patients with a dramatic improvement in their National Institutes of Health Stroke Scale (NIHSS) score 24 hours (24h) after thrombectomy were more likely to have a favorable clinical outcome than patients without a dramatic change in NIHSS in the DEFUSE 3 study.

Methods:
All patients who underwent thrombectomy in DEFUSE 3 were included. Dramatic improvement (DI) was defined as a reduction of ≥8 NIHSS or NIHSS 0-1 24h after thrombectomy. Clinical outcomes were assessed by an ordinal analysis modified Rankin Scale (mRS) score and a dichotomous analysis for functional independence (mRS 0-2) at 90 days. Pre- and post-thrombecotmy core infarction was quantified by the DEFUSE 3 core laboratory.

Results:
91 patients in DEFUSE 3 underwent thrombectomy with follow up data; 31 patients (34%) experienced DI (DI+) after thrombectomy and 60 patients (66%) did not (DI-). There were no differences in age, medical comorbidities, right sided infarction, LVO location, presentation NIHSS, treatment with intravenous tPA, or time of thrombectomy treatment between DI+ and DI-. Presentation ASPECTS and baseline infarct core and penumbra volumes were similar between these groups. Reperfusion (TICI IIB-III) after thrombectomy was achieved in 26 (84%) DI+ and 43 (72%) DI- (p=0.2). Symptomatic intracranial hemorrhage occurred in no DI+ and 8% of DI- patients (p=0.2). DI was associated with a favorable mRS shift at day 90 (OR 3.8 [CI 1.7-8.6]; p=0.001) and higher rates of mRS 0-2 (61% vs 37%) OR 2.7 [CI 1.1-6.7]; p=0.03. Mortality was 3% in DI+ vs 18% in DI- (p=0.05). DI+ patients has lower median 24h NIHSS (5 [IQR 1-7] vs 13 [IQR 7.5-21]; p<0.001), smaller 24h infarction volume (21 ml [IQR 5-32] vs 65 [IQR 27-145]; p<0.001), and less 24h infarct growth (8 ml [IQR 1-18] vs 37 [IQR 16-105]; p<0.001) compared to DI- patients. Hospital stay was shorter in DI+, 3.7 days [IQR 2.9-7.1] vs 7.4 [IQR 5.2-12.1] in DI-, p<0.001.

Conclusions:
DI following thrombectomy correlates with favorable clinical and radiographic outcomes and reduced hospital length of stay. DI was a favorable prognostic sign following late window thrombectomy in the DEFUSE 3 cohort.
Abstract WP422: Vascular Outcomes in TAVR v/s SAVR in End Stage Renal Disease Patients
Authors: Vindhyal Mohinder Reddy , Vindhyal Shravani , Ndunda Paul , Khayyat Sinan , Fanari Zaher
Published: January 2019

Background:
End-stage renal disease patients undergoing dialysis have higher stroke risk causing significant comorbidity and mortality in patients undergoing cardiac surgery procedures. Transcatheter aortic valve replacement(TAVR) has been approved by the Food and Drug Administration's (FDA) as an alternative to surgical aortic valve replacement in patients with intermediate and high-risk comorbidities. Several observational studies have been published but very little data is available on outcomes with both of these procedures in patients on dialysis.

Methods:
We performed a meta-analysis of the observational studies which have transcatheter aortic valve replacement vascular outcomes in End-stage renal disease patients on dialysis from three different databases. Medline, Cochrane, and Web of Science were systematically searched for relevant studies and were screened by two independent investigators. Robins-I tool was used to analyze and assess the bias from the relevant studies.

Results:
Five studies were included in the analysis (Three of the studies were propensity-matched and the other two included cox proportional hazard model) including 619 TAVR and 697 SAVR patients. The overall risk of bias judgment for the propensity-matched studies was low and for the two cox proportional hazard models were low to moderate in bias due to confounding. TAVR patients on dialysis had similar major stroke 2.1% vs 3.8% [0.58 (CI: 0.29, 1.14); P value = 0.93, I2 = 0%], minor stroke rate of 2% vs 2% [1.0 (CI: 0.23, 4.43); P value = 0.37, I2 = 1%], major vascular complication rate of 4.2% vs 5.7% [0.73(CI: 0.38, 1.38); P value = 0.67, I2 = 0%], minor vascular complication rate of 8.4% vs 9.9% [0.83(CI: 0.51, 1.35); P value =0.49, I2 = 0%], major bleeding rate of 4.8% vs 6.5% [0.73(CI: 0.034, 1.60); P value = 0.58, I2 = 0%] and pacemaker insertion rate of11.9% vs 6.5% [1.93(CI: 1.28, 2.90); P value = 0.43, I2 = 0%].

Conclusions:
Although the available data from observational studies show almost similar vascular outcomes in TAVR and SAVR in dialysis patients. There is definitely a trend showing lower major stroke rate, lower major and minor vascular complications but higher pacemaker implantation rate in TAVR group when compared to the SAVR.
Abstract WP423: Use of Non-Vitamin K Antagonist Oral Anticoagulants for the Treatment of Cerebral Venous Sinus Thrombosis
Authors: Giles James A , Balasetti Vamshi K , Zazulia Allyson R
Published: January 2019

Introduction:
The management of cerebral venous sinus thrombosis (CVST) is a common problem facing vascular neurologists. AHA/ASA guidelines suggest the use of heparin followed by vitamin K antagonists (VKA) for anticoagulation in CVST. In recent years, the evidence base has solidified for the use of novel oral anticoagulants (NOACs) in lower extremity DVT. Since data supporting their use in CVST is very limited, we sought to review our experience with NOACs in the treatment of CVST at a tertiary care center to address efficacy and safety.

Methods:
We retrospectively reviewed charts of all patients with CVST treated at our facility with a NOAC between 2014-2018. We collected data on demographics, risk factors for CVST, clinical features at presentation, imaging results, anticoagulation regimen, bleeding complications, and disability at follow up. We compared disability at follow up and major hemorrhagic events with historical controls.

Results:
We identified 27 patients with CVST treated with a NOAC, 22 of whom had follow up within our system. NOACs included apixaban (68.2%), rivaroxaban (27.3%) and dabigatran (4.5%). NOAC use was associated with stabilization of clot or partial recanalization in 81.8% of patients, and complete recanalization in 18.2%, at a median follow up of 5.5 months. Median mRS at follow up was 0, with one death. Four patients had bleeding complications, including two with symptomatic worsening of ICH. Comparison to historical controls showed no significant differences in terms of disability, death or major hemorrhagic events.

Conclusion:
Safety and efficacy of NOAC use for CVST were similar to historical controls anticoagulated with other agents. Analyses comparing NOAC-treated patients to 40 contemporary controls treated with vitamin K antagonists at our institution are underway, and prospective assessment of NOAC efficacy and safety in CVST in randomized controlled trials is warranted.
Abstract WP426: Cerebral Amyloid Angiopathy-related Inflammation: Immunosuppressive Treatment and Outcome
Authors: Thon Jesse M , Regenhardt Robert W , Thon Olga R , Charidimou Andreas , Viswanathan Anand , Gurol Mahmut E , Chwalisz Bart K , Frosch Matthew , Cho Tracey A , Greenberg Steven M
Published: January 2019

Introduction:
Cerebral amyloid angiopathy-related inflammation (CAAri) is characterized by altered cognition, headaches, and seizures and is associated with vasogenic edema and an anti-amyloid immune response on imaging and histology. Optimal treatments are poorly understood. Our objective was to analyze clinical features and treatment strategies in CAAri to identify predictors of outcome.

Methods:
We retrospectively reviewed the records of 56 consecutive patients with pathologically or radiographically diagnosed CAAri at Massachusetts General Hospital. Clinical, laboratory, pathology, and treatment data were collected for analysis. Inflammatory events were defined by previously described clinical and radiographic parameters. Chi-Square analyses were used to determine if treatment with immunotherapy was associated with outcomes.

Results:
Of the 56 subjects, 8 had vessel wall inflammation on pathology, 21 had perivascular inflammation on pathology, and 48 had probable CAAri by validated imaging criteria. Thirty-five were female, 49 presented with an inflammatory event, and the mean age at first event was 69.3+/-10.2 years. First events included headache (n=21), cognitive/behavioral change (29), focal deficit (9), seizure (20), and other (6). CSF was examined in 26 subjects after first event (6 with WBC>5, 24 with protein>45, 1 without abnormality). Treatments included steroids (33), cyclophosphamide (6), mycophenolate (2), and no treatment (14). After first event, clinical improvement (n=39) was more likely if treated with any immunotherapy than not (32/34 vs 7/14, p=0.001). Radiographic improvement (28) was more likely if treated than not (24/28 vs 4/14, p<0.0001). Radiographic worsening (13) was less likely if treated than if not treated (3/28 vs. 10/14, p<0.0001). Only 3 had clinical worsening and 0 were unchanged. At least 1 recurrent event (19) was more likely if not treated than if treated (10/13 vs 9/31, p=0.005); 10 had multiple recurrences and 1 died during an event.

Conclusion:
This study of the largest CAAri patient population to-date suggests treatment with immunosuppression is associated with improved clinical and radiographic outcomes and decreased recurrence of events.
Abstract WP428: Inter-professional Process Improvement Initiative to Enhance In-hospital Stroke Alerts
Authors: Perrin Stacy M , Senter Catherine
Published: January 2019

Background:
Annually, 17% of all strokes occur during hospitalization. Compared to individuals with stroke who present to the emergency department, the prognosis for individuals with an in-hospital stroke is worse. Patients with in-hospital strokes experience higher NIHSS scores, Modified Rankin scores, and increased mortality rates. An inter-professional stroke committee conducted a process improvement initiative to enhance in-hospital stroke alerts and treatment rates.

Methods:
The Plan-Do-Study-Act model was used to guide this initiative. Upon initial review, outdated policies and procedures for in-hospital stroke alerts were identified. First, evidence supported the need to add a rapid response nurse to the stroke alert response team to facilitate immediate care of patients, to transport them to CT and the Stroke Unit. Second, the process for hospital staff to call stroke alerts was revamped. An educational program was designed to empower all clinical and non-clinical staff members to call in-hospital stroke alerts. The program included ACT FAST education and the new in-hospital stroke alert procedure. A variety of training modes were used to disseminate the education: new hire orientation (n=836), in-services (n=257), and computer-based learning (n=903) for a total of 1996 staff members trained from February-August 2018.

Results:
Post-training data collection is ongoing; however, preliminary analysis has been conducted. Prior to the education about the new process, 70 stroke alerts were called, 12 were accurate (17%) and 4 were treated (33%). During the education period, 56 stroke alerts were called, 18 were accurate (32%) and 6 were treated (33%). Currently, all employees receive in-hospital stroke alert training during orientation and annually. Monthly inter-professional stroke committee meetings include monitoring of the new process allowing for timely discussions and adjustments.

Conclusion:
The goal of the initiative has partially been met by using a team approach and the Plan-Do-Study-Act model. Improvements in stroke alerts accuracy have been observed while treatment rates are currently similar. Updates to the process were possible with collaboration among team members to improve outcomes for the in-hospital stroke patients.
Abstract WP429: Choosing Wisely: Is 24 Hour ICU Monitoring Post-tPA Really Necessary?
Authors: Merbach Dawn , Lawrence Erin , Khan Sheena , Soto Alexandria , Marsh Elisabeth B
Published: January 2019

Introduction:
After treatment with intravenous tissue plasminogen activator (IV tPA) or intra-arterial thrombolysis (IA lysis) patients are monitored intensely for evidence of change in neurological examination and possible intracranial hemorrhage (ICH) for 24 hours. This typically requires an intensive care unit and significant nursing resources. The half-life of IV tPA and resulting coagulopathy is much shorter. Therefore, patients may not require such prolonged monitoring. We evaluate the frequency and timing of change in neurological examination for patients treated with IV tPA and IA lysis for acute stroke.

Methods:
All patients presenting with acute ischemic stroke who were treated with IV tPA and/or IA lysis at our institution between 2016 and 2018 were prospectively followed per protocol for 24 hours post-treatment for changes in neurological examination (every 15 minutes x 8, every 30 minutes x 12, hourly thereafter up to 24 hours). Any neurological deterioration (level of consciousness, cranial nerves, motor, sensory), exam changes occurring after 12 hours, and those requiring action (eg., noncontrast head CT) were recorded, along with patient demographics, medical variables, stroke severity, and outcomes.

Results:
172 patients were treated (IV:135, IA:64, both:30). 107 patients (63%) were noted to have a change in neurological examination at some point during the first 24 hours of admission; however only 11 (6%) had changes after 12 hours post-treatment that were not associated with a nursing shift change, and only 3 of these changes resulted in additional action (head CT) by the medical team. None of these patients required additional intervention (none were diagnosed with ICH). Higher stroke severity (p=0.033) was associated with a change in exam (though not after 12 hours), and changes in exam were associated with higher discharge (p=0.001) and 90 day modified Rankin scores (p<0.001).

Conclusion:
Patients with more severe strokes are more likely to have changes in neurological examination following acute stroke treatment, especially within the first 12 hours. Significant change in exam after 12 hours is uncommon. This may indicate that prolonged intensive monitoring in an ICU setting is unnecessary post-tPA.
Abstract WP431: Advance Directives and Comfort Measures Only During Stroke Hospitalization
Authors: Lank Rebecca J , Shafie-Khorassani Fatema , Ortiz Carmen , Kim Sehee , Sánchez Brisa N , Case Erin , Morgenstern Lewis B , Zahuranec Darin B
Published: January 2019

Introduction:
Advance directives are often promoted as a way to ensure that patient wishes are followed; however, the impact of advance directives on actual care is controversial, and little is known about the impact on in-hospital stroke treatment. We explored the association between pre-stroke advance directives and transition to comfort measures only (CMO) during stroke hospitalization among patients with surrogate-decision makers.

Methods:
Ischemic stroke and intracerebral hemorrhage (ICH) stroke cases from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Patient records were abstracted for time to CMO. Surrogates were asked about patient pre-stroke advance directives (advance directive, living will, or durable power of attorney for health care). Cox-proportional-hazards models assessed the relationship between advance directives and time to CMO (censored at death, discharge, or 30 days). Based on the available sample size, adjustment factors were pre-specified and included age, NIHSS, and stroke type.

Results:
144 stroke patients were included (ischemic 76%; ICH 24%; age ≥75 45%; female 52%; Mexican American (MA) 59%, NIHSS mean (SD) 13(11)). 22% of cases transitioned to CMO during the hospitalization (median time to CMO 3 days); 39% of patients had an advance directive. Younger individuals, MAs and men were less likely to have advance directives. After adjusting for stroke type, age, and NIHSS, advance directives were not associated with time to CMO (Table).

Conclusions:
Fewer than half of stroke patients had advance directives; however, the presence of advance directives did not appear to impact in-hospital transitions to CMO, suggesting limited utility of advance directives. Further study in larger samples is needed to determine the best way to ensure patient wishes are followed after stroke.
Abstract WP433: Effect of Race on Rates of Patent Foramen Ovale Closure during Acute ischemic Stroke Hospitalization in the United States
Authors: Orjuela Karen D , Lekoubou Alain , Kinfe Bishu , Ovbiagele Bruce
Published: January 2019

Background:
Published data indicate that African American stroke patients are significantly less likely than their non-Hispanic White counterparts to receive therapeutic procedures in acute ischemic stroke (AIS). Little is known about frequency of PFO closure for secondary stroke prevention by race among patients with cryptogenic stroke.

Objective:
To investigate trends in PFO closure among hospitalized patients in the U.S., with an emphasis on treatment by race.

Methods:
The Nationwide Inpatient Sample was queried from 2006 to 2014 for all patients older than 18-years of age with a primary diagnosis of AIS who had procedure codes for PFO closure excluding congenital heart disease. We utilized multivariable logistic regression analyses to study the independent association between race and trends in PFO closure.

Results:
A population of patients with AIS (n=1028565), excluding congenital heart disease, was analyzed. The queried was divided by PFO closure (n=384) and no PFO closure (n=1028181). Demographic variables included age, gender (male or female) race (White, African American, Hispanic, others) and payer status (Medicare, Medicaid, private, other). In multivariable logistic regression, the odds to have a PFO closure was greatest in the 18-45 age group [age 45-65 (Odds Ratio [OR]: 0.27, 95% CI: 0.20-0.35); age 65-84 (OR: 0.11, 95% CI: 0.81-0.15); age ≥85 (OR: 0.02, 95% CI: 0.01-0.05)], no difference among genders was found (OR: 1.14, 95% CI: 0.93-1.40). African Americans were less likely have PFO closure (OR: 0.51, 95%, CI: 0.35-0.74) when compared to Whites. Private insurance (OR: 1.5, 95% CI: 1.16-2.16); urban teaching hospitals (OR: 3.0, 95% CI: 1.35-6.83); higher median household income for patient’s ZIP code (OR: 2.14, 95% CI: 1.46-3.11); higher Charlson’s Comorbidity Index (OR: 0.78, 95% CI: 0.68-0.90) and admission in 2011-2014 (OR: 0.49, 95% CI: 0.31-0.78) were found to increase the likelihood of having a percutaneous PFO closure after an AIS.

Conclusions:
Over the last decade in the U.S., being African American was associated with a significantly lower likelihood of receiving percutaneous PFO closure. Now that the beneficial role of PFO closure for cryptogenic stroke is established, this racial disparity needs to be monitored and bridged.
Abstract WP436: White Matter Lesion Severity is Associated With Intraventricular Hemorrhage in Patients With Intracerebral Hemorrhage
Authors: Vagal Vaibhav , Behymer Tyler P , Sawyer Russell P , Stanton Robert J , Flaherty Matthew L , Moomaw Charles J , Sanford Carson V , Haverbusch Mary , Mistry Eva A , Sekar Padmini , Coleman Elisheva R , Woo Daniel
Published: January 2019

Background:
Both intraventricular hemorrhage (IVH) and white matter lesion (WML) severity are associated with higher rates of death and disability among cases of intracerebral hemorrhage (ICH). Prior reports suggest higher WML burden is associated with propensity of IVH. However, those analyses were not stratified by location. Our objective was to investigate the hypothesis that a higher degree of WML would be associated with a higher risk of IVH after controlling for ICH location.

Methods:
The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) III study was a prospective study of hemorrhagic stroke in the Greater Cincinnati/Northern Kentucky region. We utilized the interviewed cohort from the study and systematically graded WML using the Van Swieten Scale (0-4) and presence or absence of IVH in baseline head CT scans. Additional variables included ICH volume, location of ICH and vascular risk factors. We used multiple logistic regression with backward elimination to adjust for relevant covariates.

Results:
Among the included 426 ICH patients (mean± SD age 71.2± 13.8; 49% females), 161 (38%) had presence of IVH. In patients with IVH, the proportion of severe WML (39.7%) was significantly higher compared with patients without IVH (27.2%) (p=0.0044). The median volume of ICH was 14.4 mL (IQR, 4.9-46.3) in patients with IVH as compared with 8.9 ml (IQR, 2.6-20.8) in patients without IVH (p<0.0001). In multivariate analysis, moderate WML, severe WML, deep ICH location, and increasing ICH volume were independently associated with presence of IVH.

Conclusion:
Moderate to severe white matter lesions are a risk for intraventricular hemorrhage. Further studies are needed to determine if greater severity of IVH or subsequent rupture into IVH are associated with higher grades of WML.
Abstract WP437: The CT Angiography Spot Sign, Hematoma Expansion and Functional Outcome in Spontaneous Cerebellar ICH
Authors: Singh Sanjula D , Brouwers Bart , Schreuder Floris , Morotti Andrea , Pasi Marco , Warren Andrew , Douwes Jules , Senff Jasper , Schwab Kristin , Rosand Jonathan , Greenberg Steven , Viswanathan Anand , Klijn Catharina , Rinkel Gabriel , Goldstein Joshua
Published: January 2019

Background:
The CT angiography (CTA) spot sign is associated with hematoma expansion, mortality and poor functional outcome in supratentorial and pontine spontaneous intracerebral hemorrhage (ICH). However, no studies are available on the spot sign in patients with spontaneous cerebellar ICH. We therefore aim to assess its association with hematoma expansion and outcome in cerebellar ICH.

Methods:
We investigated consecutive patients with spontaneous cerebellar ICH treated non-surgically at three academic hospitals between 2002 and 2017. We determined patient characteristics, presence of the CTA spot sign, baseline hematoma volumes, hematoma expansion (>33% or >6ml), speed of expansion (baseline hematoma volume/time onset-CT scan) and in-hospital and 90-day mortality and functional outcome. Associations were tested using uni- and multivariable logistic regression.

Results:
We included 358 patients with cerebellar ICH of which 181 (51%) underwent a CTA. Of these 181 patients, 60 (33%) were treated surgically and therefore excluded from this study. This resulted in 121 patients of which 15 (12%) had a CTA spot sign. In univariable analyses, patients with a CTA spot sign presented with larger hematoma volumes [median (IQR): 22 (7-41) vs. 6 (3-14), p=0.005], higher rates of hematoma expansion [50% vs. 24%, p=0.167] and higher speed of expansion [median (IQR): 9 (21-2) vs. 2 (5-0), p=0.015]. Patients also had higher mortality at discharge [80% vs. 18%, p=<.001] and 90-days [80% vs. 26%, p=<0.001] and higher rates of poor functional outcome (mRS 4-6) at discharge [93% vs. 63%, p=0.020] and 90-days [93% vs. 53%, p=0.006]. In multivariable analyses correcting for age, sex and speed of expansion, the presence of the CTA spot sign is independently associated with 90-days mortality [OR 3.9, 95%CI 1.5-12.9] and 90-days poor functional outcome [OR 4.1, 95%CI 1.2-21.0].

Conclusions:
In patients with spontaneous cerebellar ICH, the CTA spot sign is associated with hematoma expansion, speed of hematoma expansion, mortality, and poor functional outcome. This may assist physicians in the risk stratification of patients with spontaneous cerebellar ICH.
Abstract WP438: Hematoma Expansion and Outcomes in Vitamin K versus Non-Vitamin K Antagonist Oral Anticoagulation Related Intracerebral Hemorrhages
Authors: Miller Malgorzata M , Lowe Jessica , Khan Muhib , Azeem Muhhamad U , Jun-O'Connell Adalia H , Goddeau Richard P , Moonis Majaz , Gritters Danielle , Silver Brian , Henninger Nils
Published: January 2019

Background:
There is mounting evidence that functional outcome after intracranial hemorrhage (ICH) related to non-vitamin K antagonist oral anticoagulation (NOAC-ICH) is similar if not better as compared to vitamin K antagonist (VKA)-related ICH (VKA-ICH). This has been partially attributed to a smaller initial hematoma volume (HV). However, the association with other hematoma characteristics such as hematoma expansion (HE) are not well understood.

Methods:
We retrospectively analyzed 102 consecutive patients with acute non-traumatic ICH on oral anticoagulation therapy to compare HV and HE, and their relation to the 90-day modified Rankin scale (mRS) score.

Results:
A specific reversal agent was used in 72 (93.5%) VKA-ICH versus two (8%) NOAC-ICH. In unadjusted analyses, VKA-ICH (n=77) and NOAC ICH (n=25) had a similar admission HV (p>0.05) and HE (p>0.05), and NOAC-ICH patients more frequently had lower 90-day mRS scores than VKA-ICH patients (p=0.017). After adjustment, an unfavorable 90-day functional outcome (mRS 4-6) was independently associated with lower admission Glasgow coma scale score (OR 1.63; 95%-CI 1.26-2.10; p<0.001) and greater HV (OR 1.03; 95%-CI 1.00-1.05; p=0.046), but not the oral anticoagulant strategy (OR 2.85; 95%-CI 0.69-11.86; p=0.15). After exclusion of patients without follow-up head CT to allow for adjustment by the HE, VKA-ICH was associated with an approximately 3.5 times greater odds for a poor 90-day outcome (OR 3.64; 95%-CI 1.01-13.09; p=0.048).

Conclusions:
Our observations support the notion that NOAC does not relate to a worse ICH extent and post-ICH functional outcome, information that may aid clinical decision making if confirmed in prospective studies.
Abstract WP439: Diagnostic Yield of MRI/MRA in 400 Patients With Spontaneous Intracerebral Hemorrhage
Authors: Chalouhi Nohra , Das Somnath , Mouchtouris Nikolaos , Al-Saigh Fadi , Tjoumakaris Stavropoula , Rosenwasser Robert , Jabbour Pascal
Published: January 2019

Background:
It is common practice to perform MRI and MRA to identify secondary causes of intracerebral hemorrhage (ICH). The utility of MRI/A in this setting has not been adequately studied, and the guidelines of the AHA/ASA on ICH do not indicate which patients require further imaging with MRI/A.

Objective:
To determine the yield of MRI/MRA in spontaneous ICH and stratify the results in different subgroups of patients.

Methods:
Patients with spontaneous ICH as diagnosed on non-contrast head CT who underwent further evaluation with an MRI/A between 2015 and 2017 at our institution were included in the study. Patients with known vascular/neoplastic lesions prior to admission were excluded. MRIs and MRAs were reviewed to identify underlying neoplastic or vascular lesions namely arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, sinus thrombosis, or moyamoya disease.

Results:
A total of 400 patients were identified. Mean age was 65.3±15.8 years. ICH locations were as follows: lobar (48%), basal ganglia (35.3%), cerebellar (12.3%), and pontine (4/5%). The overall diagnostic yield of MRI/A was 12.5%. In multivariate analysis, factors predicting positive findings on MRI/A were younger patients (p<0.001), nonbasal ganglia location (p=0.006), and absence of vascular risk factors (p=0.007). Importantly, the diagnostic yield of MRI/A was 0% in patients > 63 years with a basal ganglia hemorrhage, and those > 85 years with any ICH location. Conversely, the yield of MRI/A was 45% in those ≤50 years.

Conclusion:
Based on the results from a large cohort of patients with spontaneous ICH, we do not recommend obtaining MRI/A in patients > 85 years and those > 63 years with ICH in the basal ganglia. In all other situations, MRI/A remains indicated to rule out underlying lesions.