bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract NS19: A Bird’s Eye View: A System-Wide Approach to Reducing Stroke Readmissions
Authors: Brackman Jennifer M , Samblanet Kerri , McGee Angela
Published: March 2022

Background:
In January of 2013, Aultman Hospital was selected among 500 hospitals nationwide to participate in the Centers for Medicare and Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) Initiative. The hospital chose to participate using the stroke patient population during the acute hospital stay and services up to 90 days after hospital discharge. During the discovery phase, data was analyzed that helped to identify opportunities for stroke patients across the continuum of care.

Purpose:
To identify areas of opportunity to reduce all-cause readmissions and to improve transitions of care across the continuum for stroke patients.

Methods:
A multi-disciplinary steering committee came together to review the analyzed data and identify care coordination opportunities. Reviewed data included stroke patients from 2008 to current, with a strong focus on readmissions and complications of care. A care coordinator position was created to follow all Medicare stroke patients for 90 days following discharge. The position provides a consistent person that would ensure that individual needs are met across the continuum and possibly prevent readmissions. Several interventions have been initiated that have helped to prevent readmission to the hospital system such as: facilitation of visiting physician for home bound patients, obtaining therapy orders for patients post-discharge, medication counseling, referrals to physicians when appropriate, and providing family support.

Results:
In 2012, the all-cause readmission rate for stroke patients was 8.8%. In 2013, the readmission rate for stroke patients was 9.4%. From January of 2014 to April of 2014, the readmission rate decreased to 9.0%. After implementation of the high risk care coordinator position in May of 2014, the readmission rate has decreased to 5.8%.

Conclusions:
Throughout Aultman’s journey with the BPCI, common themes remain: the need for collaboration of services for stroke patients to ensure continuity of care and to streamline the encounter for the patient. Aultman’s BPCI for Stroke team was able to identify ways to reduce stroke readmissions, prevent complications of care for stroke patients, and reduce the overall financial impact to an overburdened public health system.
Abstract NS20: Discharge Disposition After Intracerebral Hemorrhage
Authors: Osborne Jennifer , Langefeld Carl D , Moomaw Charles J , Sheth Kevin N , Hwang David Y , Flaherty Matthew L , Vashkevich Anastasia , Gohs Julie , Woo Daniel
Published: March 2022

Introduction:
We sought to explore factors that determine discharge disposition after ICH to home-like environment vs. medical facility in the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study.

Methods:
ERICH is a multi-center, prospective case-control study of ICH among white, black, and Hispanic patients. Hospital discharge data at 19 study centers were collected through chart review. Analysis was restricted to those with pre-stroke modified Rankin Scale (mRS) < 3, available ICH volume, and survivors. ICH volumes were log transformed to minimize the influence of extreme values on modeling.

Results:
Between 8/1/10 and 12/31/13, 2276 ICH cases were enrolled, of whom 1499 qualified for analysis (564 black, 513 Hispanic, and 422 white). Univariate analysis examined demographics, past medical history, ICH location, discharge mRS, intraventricular extension, social status (education level, marital. status, employment), and type of insurance. Of the 1499 cases, 541 (36.1%) were discharged to home-like settings (home, relative, or friend) and 958 (63.9%) to medical care (rehabilitation, skilled nursing facility), assisted living, hospital/acute care). In multivariable modeling (Table), significant predictors of discharge disposition were measures of severity (i.e., ICH volume, Glasgow Coma Scale) and ICH location. In addition, types of insurance, age, and ethnicity were significant. Specifically, black ICH cases were more likely to go to a medical facility than Hispanics rather than discharge to home after controlling for severity measures.

Conclusion:
Age, ethnicity and insurance status were independent predictors of discharge to a medical facility rather than to home even after controlling for stroke severity measures of ICH volume and presenting GCS. Future analysis is needed to look at 3 month functional outcome was affected by the discharge disposition.
Abstract T MP22: Ly6g/c Monocytes Within The Spleen May Be An Important Target For Bone Marrow Mononuclear Cell Therapy In Stroke
Authors: Yang Bing , Kaushik Parsha , Schaar Krystal , Xi Xiaopei , Aronowski Jaroslaw , Savitz Sean
Published: March 2022

Background:
We and other investigators have demonstrated that autologous bone marrow mononuclear cells (MNCs) improve stroke recovery in animal models. We assessed whether the spleen, a major homing organ after MNC administration, is a key target organ associated with the benefits of MNCs.

Methods:
C57 mice underwent stroke and were treated with autologous bone marrow MNCs or saline IV at 24 hours after stroke. At various time points, spleens were harvested and flow cytometry of the splenocytes was performed (n=4, per group at each time point). In a separate experiment, C57 mice underwent splenectomy two weeks prior to stroke, and then were treated with autologous MNCs IV or saline at 24 hours after stroke (n=10 each group), compared with mice who had intact spleens and were treated with autologous MNCs or saline at 24 hrs after stroke (n=8 to 12 each group). Behavior testes were evaluated up to the 28 days after stroke using corner and ladder rung tests.

Results:
Compared to the saline group, MNC treatment did not change the proportion of B cells, CD4 T helper cells, CD8 T cytotoxic cells, Treg cells or NK cells among splenocytes at any time points tested. However, there was an increased proportion of monocytes in MNC treated animals after stroke compared with saline treated animals (
p=
0.01 at 1 hour, 0.07 at 3hrs, 0.04 at 6 hrs and 0.09 at 24hrs). The Ly6G/C positive cell population among the monocytes were elevated in the MNC group (
p
=0.01 at 1 hour, 0.09 at 3hrs, 0.08 at 6 hrs and 0.04 at 24hrs). Neural deficits and lesion size were lower in mice without spleens compared to mice with intact spleens. In mice without spleens, MNCs compared with saline had no effect on functional recovery.

Conclusion:
Treatment with autologous MNCs may alter specific subpopulations of monocytes in the spleen. The spleen might be a key target organ associated with recovery after treatment with MNCs for stroke.
Abstract T MP28: Rigorous Anesthetic Management Protocol for Prevention of Perioperative Stroke in Patients with Intracranial Arterial Stenosis
Authors: Ooi Yinn Cher , Van De Wiele Barbara , Ziv Keren , Saver Jeffrey , Gonzalez Nestor
Published: March 2022

Introduction:
Perioperative ischemic stroke results in increased morbidity and mortality. As part of the ongoing EDAS Revascularization for Symptomatic Intracranial Arterial Stenosis (ERSIAS) Trial we have developed a strict anesthesia protocol to prevent fluctuations in patient parameters affecting cerebral perfusion: systolic blood pressure (SBP) and end-tidal CO2 (ETCO2). The hypothesis of this study is that the ERSIAS Anesthesia Management protocol reduces the variability of SBP and ETCO2 compared with a control group of non-stenosis-related vascular neurosurgical interventions.

Methods:
This is a prospective matched controlled cohort study of patients undergoing EDAS surgery vs. standard neurovascular interventions. ERSIAS patients had strict perioperative management including intentional hypertension and normorcarbia, meticulous fluid balance management, and antiplatelets use. Control patients received routine anesthetic standard of care. Minute-by-minute intra-operative vitals were electronically collected. Heterogeneity of variance test was used to compare variance across groups. Vitals standard deviations were compared with Welch’s tests for unequal variances and mean values were compared with t-test and Wilcoxon rank sums as appropriate.

Results:
Study population: 10 ERSIAS Trial patients (7 ICASD, 3 MMD) and 11 controls (7 aneurysm, 4 AVM), aged 27 to 75 (mean 51, SD: 15.0), 19 females (91%). There were significant reductions in the variability of SBP and ECO2 in the ERSIAS group below the permutation simulation computed lower boundary decision limit (p<0.05). There was a significant reduction in the SBP SD 31.45 vs. 34.97 (p=0.035), and a trend reduction in ETCO2 SD 2.65 vs. 3.35. As intended, the mean ERSIAS cases SBP and ETCO2 were higher (149.5 vs. 110.9, p<0.0001, and 36.5 vs. 31.2, p=0.0006, respectively). No patients in either group presented strokes.

Conclusions:
The rigorous ERSIAS peri-operative management protocol was successful in reducing intraoperative fluctuations of blood pressure and ECO2. The protocol was also successful in achieving the intended hypertension and normocarbia.
Abstract T MP30: Biomarkers for the Evaluation of Vulnerability in Carotid Atherosclerotic Plaques
Authors: Motoyama Rie , Saito Kozue , Tonomura Shuichi , Toyoda Kazunori , Nagatsuka Kazuyuki
Published: March 2022

Background and Purpose:
Several biomarkers, such as the soluble CD40 ligand (sCD40L), Matrix metalloproteinase-9 (MMP-9), Interleukin-6 (IL-6), and vascular endothelial growth factor (VEGF), have been known as biomarkers associated with plaque vulnerability in coronary arteries. However, their clinical utility in carotid atherosclerosis remains unknown. The aim of this study was to assess the availability of these biomarkers for the assessment of plaque vulnerability in the patients with carotid artery stenosis.

Methods:
Between May 2013 and June 2014, the patients with carotid atherosclerotic plaques were enrolled in this study. These patients were divided into two groups (symptomatic and asymptomatic group). The baseline clinical data included age, gender, smoking habit, and the grade of carotid stenosis. Serum levels of biomarkers (MMP-9, IL-6, VEGF and plasma levels of sCD40L) were measured. We also collected the data of biochemical examination (serum total cholesterol, low-density lipoprotein (LDL) cholesterol, triglyceride, blood sugar and C-reactive protein).

Results:
We enrolled 35 consecutive patients (23 in symptomatic and 12 in asymptomatic group) with the carotid artery stenosis (NASCET 53.9 % vs. 47.8 %, p=0.59). There was no significant difference between the two groups in baseline clinical data and biochemical values. Plasma sCD40L level was significantly higher in symptomatic group than in asymptomatic group (1720 vs. 958 pg/ml, respectively, p<0.01). No other biomarkers were correlated significantly in the two groups [serum MMP-9 (171 vs. 149 ng/ml, respectively, p=0.27), IL-6 (3.7 vs. 2.7 pg/ml, p=0.24), and VEGF (56 vs. 46 pg/ml, p =0.48)].

Conclusions:
We found that the patients with symptomatic carotid atherosclerosis had higher levels of plasma sCD40L, and it may be useful to evaluate the vulnerability of carotid atherosclerotic plaques.
Abstract T MP66: The Ich Score: A Self-fulfilling Prophecy?
Authors: McCracken D. J , Lovasik Brendan P , McDougal Margaret E , McCracken Courtney E , Pradilla Gustavo
Published: March 2022

Introduction:
Spontaneous intracerebral hemorrhage (ICH) remains one of the most disabling forms of stroke. Of the prognostication models developed to aid in treatment decisions, the ICH score remains the most widely used. We hypothesize that patients with higher scores that carry a poor prognosis receive less aggressive treatment based on their expected mortality and that actual mortality rates are lower than those predicted by the ICH score.

Materials and Methods:
A retrospective analysis of 362 patients with spontaneous ICH from 2010-2013 was reviewed. ICH was due to hypertension, amyloid angiopathy, or was coagulopathy-induced. Surgical intervention was at the discretion of the treating neurosurgeon. Aggressive medical management was provided regardless of surgical intervention. 30-day mortality rates are reported.

Results:
Of the 362 patients, mortality rates based on the original ICH score were 0%, 5%, 33%, 61%, 70%, and 91%, for ICH scores of 0-5, respectively. EVD placement rates amongst groups were 3%, 18%, 46%, 58%, 21%, and 9% in scores of 0-5, respectively and significantly different between scores of 3 and 4 (p<0.001). Median modified Graeb scores, used to estimate IVH volume, were 0, 1, 5, 14, 11, and 17 in the same groups, with no difference between scores of 3 and 4. When comparing patients with ICH scores of 3 and 4, the percentages of patients with IVH were 86% and 98% (p=0.048), rates of cerebellar hemorrhage were 3% vs. 26% (p<0.001), ICH volumes were 44 cm3 vs. 49 cm3 (p=0.030), and median GCS scores were 7 vs. 4 (p<0.001), respectively. Between both groups, there was no difference in age, rate of brainstem hemorrhages, rate of surgical intervention, 30-day mortality, or time to death in patients in whom care was withdrawn vs. those who progressed to natural death.

Conclusion:
Our observed mortality rate in patients with poor prognosis ICH scores was lower than the historically quoted 97% and 99%, respectively. Higher IVH scores, ICH volumes, and cerebellar hemorrhage were not associated with increased rates of surgical intervention suggesting less aggressive treatment goals based on historical mortality rates. Scoring systems must be updated to allow for accurate prognostication and more aggressive treatment strategies.
Abstract T MP93: Statin Treatment May Reduce the Risk of Post-stroke Infections
Authors: Guo Jiang , Guo Jian , Chen Ning , Zhou Muke , He Li
Published: March 2022

Background:
Infection is common and likely detrimental after stroke, while the preventive effects of antibiotics are not satisfactory. Statin has been proved to possess pleiotropic neuropretection effects, including the anti-infection function. Previous studies have demonstrated a beneficial effect of statin in treating and preventing different infections, however, whether statin use can reduce the risk of post-stroke infection is not much clear. The purpose of this study is to investigate the influence of statin use on the risk of post-stroke infection.

Methods:
Consecutive ischemic stroke patients admitted to our Hospital form January 2011 to August 2013 were enrolled. We analyzed vascular risk factors, clinical symptoms(including dysphagia and bladder dysfunction), prestroke treatments(including statins use), laboratory data, stroke severity, interventions in hospital(including nasogastric tube and urethral catheter placement) and the development of infectious complications(pneumonia, urinary tract infection and sepsis). Logistic regression analyses were performed to test the association between statin use and post-stroke infections.

Results:
A total of 1863 patients were included and 306 patients (16.4%) developed in-hospital infections with the following distribution: 244 cases of pneumonia (13.1%), 52 cases of urinary tract infection (2.8%) and 24 cases of sepsis (1.3%). 1457 patients (78.2%) got statins treatment: 129 started before stroke (6.9%) and 1328 started in acute phase of stroke (71.3%). Univariate analysis showed that statin use in acute phase was related to a lower risk of post-stroke infections (P<0.001). After adjusting for age, gender, NIHSS, dysphagia, bladder dysfunction, nasogastric tube and urethral catheter placement, this relationship remained significant (OR 0.56; 95% CI, 0.38-0.82; P=0.003). However, prestroke statin use was not found to reduce the risk of post-stroke infections both in univariate (P=0.06) and multivariate analysis (P=0.20).

Conclusions:
Statin use in acute phase of ischemic stroke may reduce the risk of post-stroke infections.
Abstract T MP95: Treatment and Outcome of Thrombolysis Related Hemorrhage: A Multi-center Retrospective Study
Authors: Yaghi Shadi , Leon-Guerrero Christopher R , Dibu Jamil , Ali Syed , Noorian Ali Reza , Keyrouz Salah G , Schwamm Lee , Hinduja Archana , Bianchi Nicolas , Liebeskind David S , Marshall Randolph S , Willey Joshua Z
Published: March 2022

Background:
The most feared complication from thrombolysis is symptomatic intracerebral hemorrhage (sICH). Current treatments for sICH are based on limited data. We aim to the efficacy of treatments utilized.

Methods:
We conducted a collaborative study from 5 academic stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA) on acute post-thrombolysis sICH treatment. The definition of sICH was based on the Safe Implementation of Thrombolysis in Stroke criteria. The primary outcome was in-hospital mortality. Analysis was performed using Fisher’s test and independent t-test, followed by multivariable regression; p<0.05 was statistically significant.

Results:
We identified 87 patients with sICH from 1/09 to 4/14. Mean time from rtPA infusion to sICH diagnosis was 12±10 hours and mean time to treatment after diagnosis 2.5 ± 2.3 hours. 91% were diagnosed more than 2 hours from initiation of rtPA. The median NIHSS was lower in patients diagnosed in the first 3 hours versus after 3 hours (10 vs. 18, p=0.01). We found no association between receiving any treatment versus none with in-hospital mortality (37% vs 52%, p = 0.1). Factors associated with higher mortality were code status change within 24 hours (56% vs. 13%, p<0.001), endovascular treatment (27% vs. 9%, p=0.04), and pre-thrombolysis warfarin (10% vs. 0%, p = 0.04). There was trend towards lower mortality with neurosurgical treatment (13% vs. 2%, p = 0.1), and hematoma volume less than 30 cc (30% vs. 53%, p = 0.1). In multivariable models, code status change (OR = 6.2, CI 2.0-20), hematoma volume more than 30 ml (OR = 4.9, CI 1.2-19.6), and endovascular treatment (OR = 4.8, CI 1.1-20.2) were associated with increased in-hospital mortality.

Conclusion:
The treatment of post-thrombolysis sICH did not reduce mortality. Possible explanations include perception of futility, prolonged time to diagnosis, and endovascular treatment. More aggressive neurological monitoring beyond two hours from rtPA and screening high risk patients, especially those with high NIHSS score may potentially reduce time to diagnosis/treatment. Innovative treatment with high efficacy and short onset of action should be studied to improve the outcome of sICH.
Abstract T P106: Stenting for Extracranial Vertebral Artery Stenosis: Results from China Interventional Stroke Registry
Authors: Xiong Yunyun , Liu Wenhua , Liu Dezhi , Xu Gelin , Liu Xinfeng ,   CISR investigators
Published: March 2022

Objectives:
Angioplasty and stenting are attractive options for treating ECVAS. We aimed to investigate the safety and long-term clinical outcomes of angioplasty and stenting in extracranial vertebral artery stenosis (ECVAS) in China.

Methods:
Seven medical centers in China prospectively enrolled consecutive patients undergone angioplasty and stenting in ECVAS between Jan 2008 and Jan 2013. We collected patients’ clinical histories, symptoms, technical success and clinical outcomes of transient ischemic attack (TIA), stroke or death.

Results:
Two hundred and twenty-four patients with 229 treated ECVAS were included. The technical success rate and periprocedural events rate were 95.2% (218/229) and 3.9% (9/229), respectively. With a median follow-up duration of 16 months, 201 patients with 205 treated ECVAS had long-term follow-up information, the composite events rate of TIA, stroke or death was 8.0% (18/224). History of TIA (hazard ratio [HR] 5.156, 95% confidence interval [CI]: 1.427-18.626), VA tandem lesions (HR 4.113, 95% CI: 1.112-15.212) and NIHSS≥4 at discharge (HR 4.854, 95% CI: 1.525-15.391) contributed independently to the composite events.

Conclusions:
Angioplasty and stenting has high rate of technical success and low clinical events rates for ECVAS in China. Our study may lend support to perform angioplasty and/or stenting for ECVAS and help case selection for future randomized trials.
Abstract T P141: Current Cigarette Smoking Is Associated With Echodensity of Carotid Plaque in the Northern Manhattan Study
Authors: Yang Dixon , Iyer Sunil , Gardener Hannah , Della-Morte David , Crisby Milita , Dong Chuanhui , McLaughlin Consuelo , Wright Clinton B , Elkind Mitchell S , Sacco Ralph L , Rundek Tatjana
Published: March 2022

Introduction:
Many pathological mechanisms associated with smoking have been described, but studies on cigarette smoking in relation to carotid plaque morphology are lacking. Given that certain plaque compositions are more prone to cause cerebrovascular events, we sought to determine the association of carotid plaque density and cigarette smoking in an urban multi-ethnic cohort.

Methods:
This cross-sectional study analyzed 1743 stroke-free participants from the population-based Northern Manhattan Study using an ultrasonographic index of plaque echodensity, the Grey Scale Median (GSM). Echolucent plaque (low GSM) is more soft and fibrous, while echodense (high GSM) is more calcified. For individuals with multiple plaques, the mean GSM weighted by plaque area for each plaque was calculated. Quintiles of GSM were calculated among those with plaque and compared to those with no plaque as the reference. We used multinomial logistic regression models to assess the associations of current cigarette smoking with GSM, adjusting for demographics and vascular risk factors.

Results:
The mean age was 65.5±8.9 years, 60% were women, 18% white, 63% Hispanic, 19% black, 14% current smokers, 38% former smokers, and 48% never smokers. Carotid plaque was present in 58% of subjects. Current smokers were at a two-fold increased risk of being in GSM quintiles 1, 2, 4, and 5 as compared to never smokers (Table).

Conclusions:
A U-shaped relationship between current cigarette smoking and plaque echodensity is observed. Smoking is associated with both echodense calcified plaque as well as with echolucent, soft plaque that are more prone to rupture. Research is needed to determine if these vulnerable plaque phenotypes may mediate an association between cigarette smoking and clinical vascular events.
Abstract T P151: Ethnic Differences in Associations Between Short-Term Exposures to Ambient Air Pollution and the Risk of Acute Ischemic Stroke
Authors: Wing Jeffrey J , Adar Sara D , Sanchez Brisa N , Morgenstern Lewis B , Smith Melinda A , Lisabeth Lynda D
Published: March 2022

Background:
Air pollution may contribute to ethnic differences in stroke risk, but little research has been conducted in diverse US populations. We investigated the association between daily changes in ambient pollution (PM2.5 and ozone (O3)) and the risk of ischemic stroke among individuals living in a biethnic community and whether the association differed by ethnicity.

Methods:
We identified incident ischemic stroke cases from the population-based Brain Attack Surveillance in Corpus Christi (BASIC) project between 2000 and 2012. Air pollutant data were obtained from a state website. The association between average daily levels of PM2.5 and O3, measured on the same-day and lags of 1-3 days, and odds of ischemic stroke was assessed using a time-stratified case-crossover study design. We explored race/ethnicity of Mexican American (MA) and non-Hispanic white (NHW) as an interaction of the associations between air pollution and stroke.

Results:
There were 2,948 ischemic strokes during the study period. Median age was 71 years (interquartile range: 59-80); 51% were women and 56% were MA. In models combining ethnic groups, an association between lag 1 O3 and stroke was found (OR: 1.05, 95% CI: 1.00-1.10); no other significant associations were noted. Ethnic differences in the associations between PM2.5 and O3 with stroke were suggested (Figure). When stratified by ethnicity, increases in O3 were consistently associated with increased odds of stroke for NHWs, but not for MAs. Increases in same-day PM2.5 were marginally associated with increases in the odds of stroke in MAs (OR: 1.12, 95% CI: 0.98-1.27), but not for NHWs.

Conclusion:
We observed an association between previous-day O3 and ischemic stroke, but found little evidence of an association between PM2.5 and ischemic stroke. Ethnic differences in the associations with both O3 and PM2.5 and stroke were also noted, suggesting that further study of environmental influences on stroke in diverse populations is warranted.
Abstract T P152: N-terminal Pro-brain Natriuretic Peptide Predicts Short-term Functional Outcome In Acute Ischemic Stroke
Authors: Lee Jin-Hyung , Kim Kyung-Jin , Jeon Byeoung-Jun , Kim Meyung-Kug , Yoo Bong-Goo
Published: March 2022

Introduction:
N-terminal pro-brain natriuretic peptide (NT-proBNP) predicts poor outcome in cardiovascular disease. The prognostic value of NT-proBNP in acute ischemic stroke is limited and remains controversial. We sought to determine whether NT-proBNP at admission were associated with short-term functional outcome after acute ischemic stroke. Methods: We measured fasting serum NT-proBNP in consecutive 357 patients (62.2% men, mean age 65.8±13.0 years) within 3 days after the onset of acute ischemic stroke. Outcomes were measured as 3-month modified Rankin Scale (mRS) score. A good functional outcome was defined as a mRS of 0-2 points, whereas a poor outcome was defined as a mRS of >2 points. Multivariate logistic regression was used to assess association between the clinical and serological parameters including NT-proBNP and mRS scores. Results: The frequency of atrial fibrillation, heart failure, hypertension, and diabetes, the NIHSS score at admission, and the level of NT-proBNP, hs-CRP, creatine kinase-MB and D-dimer were each significantly higher in the poor outcome group (p <0.05). The cut-off values of NT-proBNP level and NIHSS score on admission for prediction of the poor outcome were 183 pg/ml (sensitivity 0.758, specificity 0.756) and 3.5 (sensitivity 0.862, specificity 0.787), respectively. In age- and serum creatinine-adjusted analysis, plasma NT-proBNP levels were significantly correlated with CHADS2 scores (partial r = 0.446, p = 0.009) and CHA2DS2-VASc scores (partial r = 0.347, p = 0.048) in stroke with atrial fibrillation and ejection fraction (partial r = -0.358, p = 0.041) and interventricular septal end diastolic dimension (partial r = 0.371, p = 0.033) on echocardiogram. Multivariate logistic regression analysis demonstrated that age of ≥65 (OR, 7.0; 95% CI, 2.48-19.83, p<0.001), presence of diabetes mellitus (OR, 2.5; 95% CI, 1.09-5.78, p = 0.03), NIHSS score of ≥7 (OR, 18.9 95% CI, 7.84-45.46, p<0.001), NT-proBNP of ≥183 pg/ml (OR, 3.0; 95% CI, 1.20-7.39, p = 0.019) were independently associated with poor functional outcome. Conclusion: Serum NT-proBNP is a useful marker for short-term outcome in acute ischemic stroke. NT-ProBNP may have a role in risk stratification for predicting poor outcome.
Abstract T P155: The Vascular Distribution of Stroke Among Patients with Hypercoagulable State
Authors: Shaban Amir , Boehme Amelia K , Ryan Matthew , Albright Karen C , El Khoury Ramy , Martin-Schild Sheryl
Published: March 2022

Background:
Hypercoagulable state (HCS) may increase the risk for acute ischemic stroke (AIS). The relationship between HCS and the location of the stroke has never been described.

Objective:
To determine if HCS is associated with an increased the frequency of strokes in specific vascular distributions.

Methods:
Patients who consecutively presented to our center with AIS between 06/2008-09/2013 were selected from our prospective stroke registry. Patients who did not receive HCS blood tests were excluded from the analysis. Diffusion weighted MRI sequences were used to identify the vascular distribution of each stroke.

Results:
Among the 1,466 AIS cases presented during the study period, 395 AIS patients met our inclusion criteria; 187 patients had an HCS (77.4% Black, 51.4% Female, 55 years median age); 208 patients did not have an HCS (60.4% Black, 42.3% Female, 56 years median age). There was no significant difference in the frequency of anterior circulation strokes (p=0.130) or posterior circulation strokes (p=0.060) between the groups. Patient with HCS were more likely to have a stroke in the posterior inferior cerebellar artery (PICA) territory (9.1% vs. 2.1%, p=0.001). After adjusting to the stroke subtype, patients with HCS were at nearly 5 times higher odds of having a PICA stroke (OR=4.47, 95%CI 1.42-14.1, p=0.010). The two groups did not differ in the frequency of anterior, middle or posterior cerebral artery strokes. We did not detect a significant difference in the vertebral artery, basilar artery or anterior inferior cerebellar artery strokes.

Conclusion:
In our sample, hypercoagulable state was associated with significantly higher frequency of PICA territory strokes. Patients with PICA distribution stroke and no cardiac or large vessel etiology identified might benefit from expanding the work-up to include hypercoagulation studies.
Abstract T P156: Awareness Of Atrial Fibrillation And Appropriate Antithrombotic Treatment Will Attenuate Stroke Severity And Improve Clinical Outcome In Acute Ischemic Stroke Patients With Atrial Fibrillation
Authors: Lee Jin-San , Heo Sung Hyuk , Nam Hyo Jung , Chang Dae-Il , Kim Yerim , Lee Seung-Hoon , Yoo Deok-Sang , Kim Joon-Tae , Park Man-Seok
Published: March 2022

Background:
Ischemic stroke due to atrial fibrillation (AF) is markedly increasing in Korea. Appropriate use of oral anticoagulants for the patients with AF is very important. We elucidated the relationship between international normalized ratio (INR) values on stroke severity and clinical outcomes in patients with acute ischemic stroke and AF.

Methods:
Study subjects were extracted from prospectively-designed stroke registries of three academic hospitals from 2003 to 2013. We selected 2,303 patients with AF who visited our hospital within 7 days after onset. Persistent or paroxysmal AF is confirmed by electrocardiography or Holter monitoring. We adopted INR values extracted in emergency room, and the initial stroke severity and functional outcome were assessed by baseline and discharge National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale.

Results:
One thousand three hundred two patients (50.1%) were aware of their AF before admission. The awareness was markedly lower than that of hypertension (88.7%) and diabetes (88.1%). After exclusion of the patients who did not know their medication history, 48.5% were not on antithrombotic treatment, 17.1% on warfarin, 25.8% on mono antiplatelet treatment, 4.1% on dual or triple antiplatelet therapy, and 4.5% on warfarin and antiplatelet. Besides, the patients who were taking warfarin with a therapeutic INR (2.0~3.0) were only 68 (3.0%). Admission and discharge NIHSS score was significantly lower in the group of patients taking warfarin (median 6, interquartile range [2,13]). Admission and discharge NIHSS scores were lowest in the group of patients with optimal INR level (admission NIHSS; INR<1.5, 8[3,14]; INR=1.5-2.0, 5.5[2,13]; INR=2.0-3.0, 4[2,10], INR ≥3.0, 5.5[2,15.75], p=0.026 and discharge NIHSS; INR<1.5, 4[1,11]; INR=1.5-2.0, 3[1,10.25]; INR=2.0-3.0, 2[0,7.75]; INR ≥3.0, 2.5[1,11.25], p=0.024)

Conclusion:
Awareness of AF has been poor and underuse or inappropriate use of warfarin was widespread. Suboptimal (INR=1.5-2.0) or optimal (INR=2.0-3.0) use of warfarin can be associated with lower initial stroke severity and clinical outcome. Therefore, the education about appropriate anticoagulation is needed for the general public and health professionals.
Abstract T P186: The Effectiveness of the Motor Component of the National Institute of Health Stroke Scale at Predicting the Functional Outcome at Discharge in Patient Receiving Endovascular Therapy
Authors: Dababneh Haitham , Zheng Huo Xiang , Sakian Sina , Arcot Karthikeyan , Bashir Asif , Tiwari Ambooj , Azhar Salman , Farkas Jeffrey , Hussain Mohammed
Published: March 2022

Background and Purpose:
The National Institute of Health (NIH) developed a standardized scale to evaluate the severity of a stroke at presentation. Predicting patient outcome after a vascular event can be very challenging. The objective of this analysis was to study the effect of the motor component of the NIH Stroke Scale (NIHSS) on a patient’s functional outcome at discharge looking at a multicenter group to further validate our observation.

Methods:
This is a retrospective analysis of all patients (n= 161) that presented to the hospitals with ischemic stroke and received mechanical thrombectomy between January 2009 and July 2014 and had all the components of NIHSS baseline documented at presentation. Statistical analysis was performed using GraphPad Prism to independently evaluate the relationship between the NIHSS components and patient functional outcome at discharge using modified rankin scale (mRS). mRS of 2 or less represented a good functional outcome. All variables were included in the analysis.

Results:
112 patients that had all variables and their NIHSS breakdown components documented were included. Group analysis including gender, mean age, mean NIHSS, Afib%, DM%, Prior Stroke % and mortality at discharge were as follows: Female 52.7%, 72.1±16.3, 15.2±7.2, 34.8%, 27.7%, 25.9% and 12.5%. All Motor components of NIHSS in order left arm, left leg, right arm, right leg had a significant correlation with poor patient outcome at discharge (95%CI -3.932- -0.9607, P<0.001); (95%CI, -3.843- -0.8714, P<0.001); (95%CI, -3.584- -0.6125, P<0.01); (95%CI, -3.539- -0.5678, P<0.01). A higher motor score at presentation correlated with a worse outcome at discharge. NIHSS was significantly correlated with poor functional outcome (95% CI 9.881 -13.423 P<0.001).

Conclusion:
Admission motor grade may serve as a good predictor of disability and mortality in patients undergoing mechanical thrombectomy with acute ischemic stroke. Further prospective study to validate such an observation is warranted.
Abstract T P187: How High Is Too High? An Analysis of the Upper Threshold for Serum FVIII in Ischemic Stroke
Authors: Samai Alyana A , Boehme Amelia K , Monlezun Dominique J , George Alexander , Dowell Lauren , Leissinger Cindy , Schluter Laurie , El Khoury Ramy , Martin-Schild Sheryl
Published: March 2022

Background:
Elevated factor VIII (FVIII) is an independent risk factor for thromboembolic events and acute ischemic stroke (AIS). Laboratory reference ranges categorize levels >150% and >200% activity as elevated and severely elevated, respectively. We sought to identify the upper limit of FVIII activity with the most clinical relevance for outcomes after AIS.

Methods:
From our stroke registry, patients admitted with AIS between 07/2008 to 10/2013 were included if FVIII levels were measured during admission. Logistic regression, was used to assess differences in baseline, in-hospital, and outcome variables in patients with FVIII elevation as compared to those with normal levels. The primary outcome was poor modified Rankin Scale (mRS) score on discharge, defined as mRS>2. Serial dichotomized FVIII levels using a 5-point incremental analysis of levels were analyzed with respect to poor outcome. The threshold yielding the largest area under the curve (AUC) was determined.

Results:
Among 1,453 cases in our registry, inclusion criteria were met for 267 patients. In our sample, in a comparison of normal FVIII levels vs. elevation >150%, and elevation >200%, patients differed significantly according to race (p=0.0017), history of diabetes (p=0.0001), and history of congestive heart failure (p=0.0401). FVIII elevation threshold of 150% was the best predictor of poor mRS on discharge (OR 3.7, 95% CI 1.77-8.05, p=0.0006) with an AUC of 0.618.

Conclusions:
FVIII elevation greater than 150% is the most clinically useful threshold for the prediction of poor clinical outcomes in the setting of AIS based on data from our center.
Abstract T P189: Pure Dysarthria and Dysarthria-facial Paresis Syndrome due to Internal Capsule and/or Corona Radiata Infarction
Authors: Tanaka Koji , Yamada Takeshi , Torii Takako , Yoshimura Takeo , Takase Kei-ichiro , Murai Hiroyuki , Kira Jun-ichi
Published: March 2022

Background and Purpose:
Pure dysarthria (PD) and dysarthria-facial paresis syndrome (DFP) are considered as rare clinical entities of dysarthria-clumsy hand syndrome, mainly due to small vessel disease. We aimed to clarify the clinical and radiographic difference between patients with PD and DFP, especially due to internal capsule and/or corona radiata infarction, using the database of wide area network-based clinical research.

Methods:
This multicenter, prospective, observational study included consecutive patients with acute ischemic stroke admitted to 4 stroke centers in Fukuoka prefecture within 7 days from the onset. We included patients with first ever stroke and presenting PD or DFP with a single ischemic lesion localized in the internal capsule and/or corona radiata. Patients with any motor-sensory disturbance or cortical symptoms were excluded. Ischemic lesion volume was calculated by the A*B*C/2 method on diffusion weighted imaging. The local ethics committee approved the collection and submission of each patient’s clinical data to the study office in Kyushu University.

Results:
Between October 2010 and April 2014, a total of 2348 patients including 1773 (1006 men, 73.3±13.1 years) with first ever stroke were registered. Of them, 12 (0.68%) patients with PD and 18 (1.02%) patients with DFP were included for the analysis. Compared to patients with PD, patients with DFP had shorter onset-to-door time (median 10.75 [7.25-27.125] hours vs. 33.75 [14.25-51.5] hours, p = 0.042), larger vertical length (C component) of ischemic lesions (median 18.75 [12-20.625] mm vs. 9.25 [6-13] mm, p = 0.008), and greater ischemic lesion volume (median 828 [291-1664] mm3 vs. 289 [120-416] mm3, p = 0.031). Ischemic lesions causing PD were located more frequently in the left hemisphere than those of DFP (92% vs. 56%, p = 0.049). There was no difference in age, sex, and vascular risk factors between patients with PD and DFP. Symptom progression after admission was seen in one PD case which worsened to DFP.

Conclusions:
In cerebral infarction of the internal capsule and/or corona radiata, DFP might be derived from larger, vertically longer ischemic lesions comparing to PD. There might be stronger association between PD and left-sided lesions.
Abstract T P201: Utility of Ordering Activated Partial Thromboplastin Time for Acute Stroke Patients in the Emergency Department
Authors: Rockwell Jean M , Olson-Mack Lindsay , Afshar Katherine
Published: March 2022

Background:
Practitioners often order coagulation studies as part of an acute stroke workup. Indiscriminate use of activated partial thromboplastin times (aPTT) is not currently supported in evidence. Pending aPTT results can delay treatment and add unnecessary cost for acute stroke patients. We sought to determine the frequency of ordering aPTT in the initial evaluation of acute stroke patients, and the utilization of results in treatment decisions.

Methods:
A retrospective review of 488 records was completed on patients presenting to two primary stroke certified hospitals between August 1, 2013 and July 31, 2014. Inclusion criteria: physician activation of a code stroke in the emergency department (ED). Exclusion criteria: stroke codes initiated after hospital admission. Charts were reviewed for evidence of an aPTT order, abnormal aPTT results, and documentation of a change in medical therapy related to the aPTT results.

Results:
After applying criteria, 409 records were included. Of these, 388 (94.9%) subjects had aPTT drawn for initial evaluation of suspected stroke. Prolonged aPTT was found in 21 of 388 (5.4%) subjects. Three of the 21 subjects with abnormal aPTT results came directly from dialysis and had received heparin therapy during dialysis. Two subjects were taking dabigatran. Nine subjects on warfarin with elevated aPTTs also had elevated PT/INRs, as did two subjects with hepatic encephalopathy. Five subjects had a slight increase in aPTT due to unknown etiology. None of the subjects had a change in medical treatment as a result of an elevated aPTT. Rather, elevated INR was cited as a criterion for withholding intravenous thrombolytics.

Conclusions:
Although aPTTs are routinely ordered in the ED for acute stroke workup, results yield little information that impact treatment decisions. Unselected use of aPTT for initial acute stroke work up can lead to increased time to treatment while results are pending and unnecessary costs. Eliminating routine use of aPTT in acute stroke evaluation will result in significant cost savings without altering treatment.
Abstract T P215: A Systemized Stroke Code Significantly Reduced Time Intervals For Using Iv t-pa Under MRI Screening
Authors: Cha Jae-Kwan , Eun-Kyu Kim
Published: March 2022

Background:
A stroke code can shorten time intervals until intravenous tissue plasminogen activator (IV t-PA) treatment in acute ischemic stroke (AIS). Recently, several reports demonstrated that MRI based thrombolysis had reduced complications and improved outcomes in AIS despite longer processing compared to CT based thrombolysis. Methods: In Jan. 2009, we implemented CODE RED, a computerized stroke code, at our hospital with the aim of achieving rapid stroke assessment and treatment. We included patients with thrombolysis from January 2007 to December 2008 (pre-stroke code period) and those from January 2009 to May 2013 (post-stroke code period). The IV t-PA time intervals and 90 day modified Rankin scores (mRS) were collected. Results: During the observation period, 252 patients used IV t-PA under the CODE RED (MRI based-208, CT based-44). The remaining 71 patients (MRI based-53, CT based-18) did not. After implementation of CODE RED, door to image time, door to needle time, and the onset to needle time were significantly reduced by 11, 18, and 22 minutes in MRI based thrombolysis. Particularly, the proportion of favorable outcome (mRS 0-2) was significant increased (from 41.5 into 60.1%, p=0.02) in post- than in pre-stroke code period in MRI based thrombolysis. However, in ordinal regression, the presence of stroke code showed just a trend for favorable outcome (OR: 0.99-2.87, p=0.059) at 90 days of using IV t-PA after correction of age, sex, and NIHSS. Conclusions: In this study, we demonstrated that a systemized stroke code shortened time intervals for using IV t-PA under MRI screening. Also, our results showed a possibility that a systemized stroke code might enhance the efficacy of MRI based thrombolysis. In the future, we need to more detailed prospective study about this notion.
Abstract T P217: Sex Differences in Clinical Presentation and Outcome: Patients Admitted to a Transient Ischemic Attack Emergency Department Observation Unit
Authors: Madsen Tracy E , Merck Lisa H , SIket Matthew S , Paolucci Gino , Tran My T , Silver Brian
Published: March 2022

Background:
There are known sex differences in presenting symptoms and outcomes of stroke patients, yet little is known about sex differences in patients with transient ischemic attack (TIA). Our aim is to conduct an exploratory study of sex differences in symptoms, clinical characteristics, and outcomes among patients admitted to an ED observation unit (OU).

Methods:
Patients seen in a large, urban, academic ED with a diagnosis of TIA and admitted to the ED OU between 4/13 and 3/14 were included. Patients were excluded if they had persistent neurological deficits, fever >100.4, heart rate <60 / >100 bpm, SBP >180 / < 100 mm Hg, pulse ox <93%, or other competing ED diagnoses. Patients were evaluated using standard blood tests, EKG, echocardiogram, ED MRI/A of the head and neck, and neurology consultation. Using bivariate analyses, women and men were compared with respect to presenting symptoms, risk factors, acute infarct on MRI/A, and recurrence of symptoms. The study was approved by the hospital IRB. Analyses were conducted using Stata 12.1.

Results:
136 patients met inclusion criteria; 52.2% were women. Women and men were similar in mean age (63.8, 95% CI 59.2 - 68.4, vs. 65.4, 95%CI 61.7 - 69.0) and percent non-white (22.5% vs. 24.6%, p=0.78). More women than men reported motor symptoms (53.5% vs. 30.8%, p=0.007), while more men reported visual changes (24.6% vs. 9.9%, p=0.02), dizziness (30.8% vs. 19.7%, p = 0.14), and symptoms coded as ‘other’ (36.9% vs. 22.5%, p=0.07). Women had longer median times of symptom duration (60 min, IQR 10 - 120, vs. 30 min, IQR 10 - 90). 25.5% of women vs. 22.0% of men had acute infarcts on MRI/A (p=0.68), and 5.7% of women compared to 1.5% of men reported recurrence of symptoms at 30 days (p=0.21).

Conclusions:
In our exploratory study of sex differences in ED TIA patients, women were less likely to report “non-traditional” symptoms, a finding contrary to current literature in stroke patients. Although these findings should be investigated in future studies of TIA patients, this may suggest an inherent bias in those referred to an ED TIA OU. Future studies should investigate potential sex differences in disposition to admission versus observation unit after TIA, cerebral distribution of acute vascular event, and the recurrence of symptoms.
Abstract T P22: Intra-Aortic Cone-Beam CT Can Shorten Puncture To Treatment Time In Acute Thrombectomy For Acute Ischemic Stroke Patients
Authors: Amano Tatsuo , Sato Masayuki , Matsumaru Yuji , Sakuma Hideyuki , Yoda Shogo , Hamada Yusuke
Published: March 2022

Background and purpose:
Conventional angiographic assessment of collateral blood flow for internal carotid artery (ICA) or basilar artery (BA) occlusion requires contralateral ICA angiography and posterior circulation angiography. The angiography of other vessels may cause time delay for endovascular therapy (EVT) in acute ischemic stroke patients. In this study, we performed intra-aortic cone-beam CT (Ao-CBCT) for assessment of collateral blood flow and analyzed visualization of collateral flow and elapsed time in EVT compare with conventional angiographic assessment.

Methods:
From July 2010 to July 2014, patients with ICA or BA occlusion among fifty seven acute ischemic stroke patients treated by EVT were enrolled. The subjects were divided into 2 groups; conventional angiography (CA) group and Ao-CBCT group. Ao-CBCT images were acquired in 20 seconds rotational scan. Contrast medium was injected from ascending aorta with 1mL/s for a total of 30 seconds by use of a 4F or 6F catheter and an imaging delay of 10 seconds. We compared patient characteristics, visualization of collateral flow and time from groin puncture to injection from guiding catheter to treatment target vessel (“puncture to treatment” time).

Results:
Twelve patients in CA group and 4 patients in Ao-CBCT group were analyzed. There was no difference in age, sex, stroke subtypes and occlusion vessel between two groups. In CA group, in addition to target vessel angiography, 2 vessels angiography (interquartile range [IQR], 1-2) were performed. Three patients in CA group were performed Ao-CBCT simultaneously. Collateral blood flow from anterior/posterior communicating artery was equally visualized by both methods. Puncture to treatment time was significantly shorter in Ao-CBCT group than in CA group (21±13 vs. 51±18 minutes, p=0.0087).

Conclusions:
Ao-CBCT can visualize collateral blood flow in major vessel occlusion and shorten puncture to treatment time compare with conventional angiography.