bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP365: Meet in CT: The Development of an Ischemic Stroke Transfer team
Authors: Hundt Beth , Mahanes Dea , May-Cowgill Melinda , Carswell Anita , Braden Karen , Souter Sarah
Published: October 2018

Background and Issues:
Our stroke center accepts patients from a large rural catchment area for advanced treatment, including endovascular intervention. An ischemic stroke transfer is initiated by the referring hospital, either by call to the transfer center with subsequent stroke team discussion, or by a formal telestroke consultation. The shortest transfer distance is 40 miles over challenging terrain, and patients are transferred by both ground and air. The stroke team needed a transfer process to expedite decision making and treatment.

Purpose:
The purpose of this project is to create an interdisciplinary ischemic stroke transfer team and protocol for the transfer of patients for possible endovascular intervention to ensure safe handover of care and reduced time from onset of symptoms to reperfusion.

Methods:
A multiprofessional team used Lean problem solving to develop a protocol for patients transferring for intervention consideration. The rendezvous location was identified as radiology to facilitate treatment decisions, bypassing the Emergency Department and the Neuro Intensive Care Unit (ICU). The team developed standard work to ensure that all providers would meet the patient and transferring agency in CT scan for rapid imaging, assessment, monitoring, and handover. Providers meeting in CT include nurses from Interventional Neuroradiology (INR), Neuro ICU or Emergency Department, and physicians from the Acute Stroke Team. Once a treatment decision is made the patient is moved to INR or the ICU.

Results:
Time from patient arrival to arteriotomy was evaluated before and after implementation. Time range pre-implementation was 21-116 minutes (n= 12, mean= 52, median=41) and post-implementation was 17-52 minutes (n=8, mean= 31.5, median 28.5). The mean door to arteriotomy time was reduced by 20 minutes and times exhibited decreased variability demonstrating increased efficiency.

Conclusion:
For patients transferring to our stroke center for advanced treatment for ischemic stroke, meeting in CT is feasible and safe. Implementation of the protocol and the response of the interprofessional team has resulted in reduced time from onset of symptoms to reperfusion and decreased variability in those times.
Abstract WP366: Prediction of Inpatient Discharge Disposition: Role of the National Institute of Health Stroke Scale
Authors: Murphy Deborah , Herial Nabeel , Years Andrea , Guba Jonathan , MacKenzie Larami
Published: October 2018

Introduction:
Severity of stroke is expected to influence length of stay and discharge destination in patients. Ability to predict the likely discharge destination may assist family communication, and efficiently mobilize appropriate hospital resources, and shorten the length of stay. In this study we used NIHSS and ICH scores to predict discharge disposition after inpatient hospitalization.

Methods:
Data collected prospectively on patients admitted to a comprehensive stroke center was extracted and multiple variables including baseline mRS, daily NIHSS, discharge diagnosis, disposition (home, acute rehab, SNF, Hospice/Death) were analyzed. Results from 402 patient-records over 6 months in this on-going study are presented. Clinical improvement was defined based on change in daily recorded NIHSS. Regression analysis was performed using SPSS 24.0 and hypotheses tested α = 0.05.

Results:
Ischemic stroke was the most common diagnosis (73%) followed by TIA (15%) and ICH (11%). Average baseline NIHSS was 5.6. Over 3 days of NIHSS recordings, clinical improvement was noted in 174 (48%), no change in 103 (29%), and worsening in 83 (21%). Discharge to home or acute rehab was more frequent with ischemic stroke compared to ICH (70% vs. 42%, p<0.001). Adjusting for age, gender and baseline stroke type and severity, the Day 3 NIHSS score was a significant predictor (p<0.001) of discharge disposition. NIHSS score of > 15 was strongly associated with discharge to SNF (p=0.02), or hospice/death (p=0.005). In this data set, the number of ICH patients was not adequate to draw conclusions re: the ICH score.

Conclusion:
Commonly available inpatient scores obtained over 3 days can help predict discharge disposition. Use of continuous inpatient data may provide a tool to mobilize and prioritize hospital resources to reduce LOS and achieve predicted discharge disposition.
Abstract WP370: Breaking Barriers for Fast Acute Stroke Treatment
Authors: Handler Diane L , Frommelt Jo Ellen E , Goldberg Suisan , Houlihan Jennifer
Published: October 2018

Background:
Timeliness of acute stroke treatment is imperative. Our 384 bed, Midwestern community hospital seeks to treat ischemic stroke tPA patients within 45 minutes of arrival. However, individual staff attitudes toward use of tPA, early treatment and teamwork appeared to be barriers to timely treatment.

Purpose:
To understand what the barriers are for fast treatment and to give staff tools to overcome.

Methods:
A carefully designed, but brief, set of survey questions concerning individual views and attitudes toward the timeliness and smooth treatment between EDP/ED nurses/Neurology was completed by EDP’s, ED Nurses and Neurologists. The data from this survey was analyzed and provided information to implement changes: 1] Immediate and collaborative feedback reporting timing and outcomes; 2] Provision of a stroke-alert algorithm attached to tPA; and, 3] Accessible education information for patients and family.

Results:
56 staff completed the survey pre intervention (PRE) and 72 post intervention (POST). In most cases the barriers were reduced POST. Top barriers identified were: Slow ED to Neurology Contact time PRE 38% and POST 21%; EDP reluctance to treat PRE 32% and POST 18%; Difficulty identifying stroke patients PRE 30% and POST 26%; Losing track of time PRE 29% and POST 19%; Delay due to time to educate patients PRE 18% and POST 19%. Treatment times PRE were an average of 52 minutes door to needle and POST an average of 45 minutes. Door to neurology contact was PRE an average 20 minutes and POST an average of 11 minutes. There was a shift of the EDP’s attitude towards tPA use for acute stroke. PRE 50% answered that tPA use for stroke is not based on existing science. POST this was reduced to 20%.

Conclusions:
While treatment time, neurology contact time, and reported barriers were improved, the clear shift in EDP collective attitude toward tPA was most important. Keeping stroke at the forefront by communicating through collaborative feedback reports appeared to keep staff engaged and accountable. Keeping algorithms and tPA education material immediately available also assisted in our treatment goals.
Abstract WP376: Nationwide And Midsouth Regional Disparities In Mortality For African American And Caucasian Aneurysmal Subarachnoid Hemorrhage Patients
Authors: Stanfill Ansley , Elijovich Lucas , Arthur Adam , Foley Ryan , Speaks Tyler , Piraino Beth , Baughman Brandon
Published: October 2018

Introduction:
Aneurysmal subarachnoid hemorrhage (aSAH) carries high mortality rates, and disparities have been reported between Caucasian and African American (AA) patients. But little large-scale data are available to examine such differences. The purpose of this study is to compare demographics and mortality outcomes for Caucasian and AA aSAH subjects using both nationwide and midsouth regional datasets.

Methods:
The nationwide sample was selected from inpatient Cerner Health Facts EMR data made available through UTHSC Center for Biomedical Informatics. The midsouth regional sample was selected from the Semmes Murphey neurosurgical clinic EMR. All subjects were selected by ICD-9 code and were seen from 2004-2016. Available demographics included age, race, gender, and admission Glasgow Coma Scale (GCS) score. Primary outcome was mortality at any time in the first month post-admission. Descriptive statistics were calculated and associations with mortality outcomes examined using t-tests, chi squares, and ANOVA as appropriate. Significance was set at
p
≤0.05.

Results:
In the nationwide dataset (N=3,924, 24% AA, 57% female), AA aSAH patients were nearly 8 years younger than Caucasians (mean age 53.7 ± 17.6 vs 61.4 ± 18.9,
p
<0.0001) and had poorer admission GCS scores (mean 11.5 ± 3.5 versus 10.8 ± 3.6,
p
<0.0001). These disparities were less marked for the regional sample (N=1,144, 44% AA, 67% female), where AA were <6 years younger (mean age 51.1 ± 13.6 vs. 56.8 ± 14.0,
p
<0.0001), and GCS scores were not significantly different between races (11.2 ± 4.9, 10.8 ± 4.6,
p
=0.16). Despite an improvement in these demographic disparities locally, regional AA have similar GCS scores as the nationwide sample (
p
=0.85) and are more likely than Caucasians to die within 1 month of admission regionally (
p
=0.003) and nationwide (
p
=0.0007).

Conclusions:
AA aSAH patients experience increased mortality as compared to Caucasians both nationwide and regionally. From this limited observational data it is not clear what other factors could be contributing to these disparities in mortality. Future work in such disparities should include more complete demographic and clinical data, information on health services access, quality, and utilization, and preexisting comorbidities.
Abstract WP379: Interdisciplinary Collaboration Sustains the Utilization of an Evidenced-based Dysphagia Screening Protocol
Authors: Roberts Monica , Roupe Karla , Halvorsen Donielle
Published: October 2018

Background and Purpose:
During implementation of an acute stroke program, areas in need of improvement were observed, including dysphagia screening, appropriate intervention and documentation. An interdisciplinary team, including a Speech Language Pathologist (SLP), selected the Yale Swallow Protocol to be used by the bedside nurse to screen patients with stroke symptoms. The Yale Swallow Protocol is a validated tool for dysphagia screening. The purpose of this project was to validate the effectiveness of using interdisciplinary collaboration to sustain the utilization of an evidence-based dysphagia screening protocol.

Methods:
Patient’s presenting with stroke symptoms are to receive a dysphagia screen within 24 hours of hospital arrival. Screening results are then to be documented in the Electronic Medical Record (EMR). Patient data abstraction revealed inconsistent application of the Yale Swallow Protocol. The interdisciplinary team then developed a training tool focused on the protocol. The SLP utilized this tool to train nurses on the protocol, appropriate intervention and documentation. Patient dysphagia screening data abstraction from the patient EMR was tabulated to include the percentage of completed documentation. The goal was a minimum average of 90% for four months. The benchmark is set by Joint Commission’s evidence of standards compliance - measures of success.

Results:
The results demonstrated sustained improvement. Eight months prior to intervention, the average dysphagia screen documentation was 85% of 203 patients. The first 3 months’ post intervention the average rate of documentation was 93% of 91 patients. The next 5 months’ post intervention demonstrated sustained and improved compliance with the average documentation at 97% of 133 patients. With a total 8-month cumulative average of 96% of 224 patients.

Conclusions:
In conclusion, the positive patient data trend demonstrates the continual utilization of the screen post intervention. Utilizing interdisciplinary collaborative efforts will yield results that are sustainable when continual awareness and educational efforts are deliberate and ongoing.
Abstract WP38: High Rates of Conversion of Anesthesia Modality in Agitated Thrombectomy Patients
Authors: Mullen Evan , Shoirah Hazem , Nistal Dominic , Wei Daniel , Dangayach Neha , Shigematsu Tomoyoshi , Kellner Christopher , Oxley Thomas , Mocco J , Mayer Stephan , Fifi Johanna , De Leacy Reade
Published: October 2018

Background:
Patients with large vessel occlusion acute ischemic stroke (AIS) undergoing thrombectomy can be disruptively agitated. We aimed to determine if procedural and neurological outcomes differ for agitated patients.

Methods:
We reviewed prospectively collected data of AIS patients undergoing thrombectomy in our tertiary center between January 2014 and July 2017. We divided patients in two cohorts based on the presence of disruptive levels of agitation. We compared the baseline characteristics, procedural details and outcomes between the two cohorts.

Results:
A total of 156 patients were included, 60 (38.5%) were agitated. The agitated cohort had lower mean ASPECTS (8.3 vs 8.8, p 0.04); but other characteristics were well-matched (age, gender, premorbid mRS, occlusion side, NIHSS and tPA status). There was a trend for longer room arrival-to-recanalization times (87.1 vs 72.9 mins, p 0.09) and higher use of general anesthesia (GA) (35% vs 24%, p 0.14) in the agitated cohort (table 1). In the agitated cohort, pre-planned GA patients had longer arrival to recanalization times when compared with monitored anesthesia care (MAC) only patients (100.5 ± 73.0 vs 75.3 ± 49.8 mins). None of the non-agitated MAC patients required conversion to GA, however 11.6% of the agitated patients were converted to GA intra-procedurally, with the longest arrival-to-recanalization time (125.1 ± 68.7) (p 0.04). Other technical details (method of thrombectomy, number of passes, complications and degree of recanalization) and outcome measures (post-operative NIHSS or good neurological outcome at 90 days) were not different between groups.

Conclusions:
Agitated patients have a high incidence of conversion from MAC to GA resulting in delay in recanalization compared to pre-planned GA. Our study was limited by a small sample size and larger studies are necessary to elucidate the impact of agitation on outcome and whether there is role for pre-planned GA in agitated thrombectomy patients.
Abstract WP382: Hospital Length of Stay in Stroke: Relationship to Feeding Status and Discharge
Authors: MacKenzie Larami , Herial Nabeel , Murphy Deborah , Years Andrea , Guba Jonathan
Published: October 2018

Introduction:
Hospital length of stay (LOS) has been associated with clinical outcome and cost of care. Factors influencing LOS provide an opportunity for cost containment and acute inpatient rehab facilitation. In patients with dysphagia, early alternative feeding options may limit malnutrition and improve rehab potential. Data linking percutaneous endoscopic gastrostomy (PEG tube) placement and LOS is limited. In this study we evaluated stroke LOS with respect to clinical severity, PEG tube, and discharge disposition.

Methods:
Prospective data on comprehensive stroke center patients was analyzed. Data analyzed includes demographics, pre-stroke Rankin Score (mRS), daily National Institutes of Health Stroke Scale (NIHSS), stroke subtype, disposition (home, acute rehab, skilled nursing facility (SNF), Hospice/Death), LOS, and PEG tube placement. Groups of mild (0-4), moderate (5-15), mod-severe (16-20) and severe (>20) were defined based on NIHSS.

Results:
390 patients over 6 months had 73% ischemic stroke, 11% ICH, and 15% TIA. Pre-stroke mRS was ≤ 2 in 87%. About 89% had mild or moderate deficits, and 11% had moderate-severe or severe stroke. Mean LOS was 4.8 days in patients without PEG versus 16.8 days in patients with PEG. PEG tube was placed in 19%, 38.5% and 40% in moderate, mod-severe, and severe stroke patients, respectively. 10% (36/361) were palliated without a PEG. Among full support patients, 21.6% moderate, 50% moderate to severe, and 83.3% of severe strokes received a PEG tube prior to discharge. Average time from admission to PEG tube consult was 3.8 ± 2.8 days. Time to PEG tube placement was 10 ± 4.7 days. Recorded reasons for PEG placement delay included family decision/consent process and fever, however the impact of scheduling was not recorded.

Conclusion:
Both stroke severity and LOS are strongly associated with PEG tube placement. PEG tube placement occurs after patient and family discussion, expert consultation, and a scheduled procedure. There may be modifiable factors such as narrative and decision making / consent, which can reduce LOS in patients with severe strokes. The authors suggest future research on this topic may include an early PEG versus palliation pathway to facilitate early discharge to rehab or SNF.
Abstract WP395: Verifynow P2Y12 Assay With Regard to Cytochrome P450 2C19 Polymorphisms and Stroke Recurrence
Authors: Han Sang Won , Park Joong Hyun , Cheon Kyeong Yeol , Lee Kyung-Yul
Published: October 2018

Background and Purpose:
No evidence as yet that clopidogrel resistance (CR) on VerifyNow assay in relation to cytochrome P450 2C19 (CYP2C19) polymorphisms are more clinically informative at predicting recurrent vascular events during follow-up after ischemic stroke (IS). The aim of this study was to perform a subgroup analysis of MESTRO study to explore the relationship between VerifyNow P2Y12 assay with regard to CYP2C19 polymorphisms and stroke recurrence in patients with non-cardiogenic IS and clopidogrel treatment.

Methods:
The methods of the MAESTRO study have been published previously. For the study, CR was tested by the VerifyNow P2Y12 assay (Accumetrics, San Diego, CA, USA). CYP2C19 genotype was classified as an ultrarapid metabolizer (UM; *1/*17, *17/*17), extensive metabolizer (EM; *1/*1), intermediate/unknown metabolizer (*1/*2, *1/*3 and *2/*17, *3/*17), or poor metabolizer (PM; *2/*2, *2/*3, *3/*3) based on CYP2C19 genotype status. UM or EM status patients were allocated into the good genotype group for clopidogrel metabolism, and intermediate/unknown metabolizer or PM status patients were allocated into the poor genotype group.

Results:
Of the 256 patients with clopidogrel treatment, 20 (7.8%) had a recurrent stroke: 15 (75%) experienced an IS and 5 (25%) experienced an ICH. Of the patients with percent inhibition (% INH) ≥40, the risk of recurrent stroke in the good genotype group was 2.2% and was not significantly different from that in the poor genotype group (6.7%) (P=0.400). There was also no significant reduction in the risk of a major vascular event between the groups (2.2% vs 6.7%, P=0.400). Of the patients with % INH <40, there was a trend towards reduction in risk for the recurrent stroke (2.1% vs 8.3%, p=0.142) and a major vascular event (2.1% vs 9.8%, p=0.081) in the good genotype group.

Conclusions:
Impaired responsiveness to the platelet P2Y12 receptor antagonist clopidogrel alone may not predict stroke recurrence.
Abstract WP397: Is Remote Ischemic Conditioning Safe in Clinical Practice : A Systematic Review
Authors: Liu Shimeng , Chen Rong , Meng Ran , Zhang Qian , Ma Qingfeng , Dong Kai , Huang Xiaoqin , Xue Sufang , Yu Zhipeng , Chu Changbiao , Song Haiqing , Ji Xunming , Feng Wuwei
Published: October 2018

Introduction:
Remote ischemic conditioning (RIC) has been investigated for its protective effect for heart disease, stroke prevention, etc. However, the safety and tolerability of RIC have not been systematically investigated. We aimed to conduct a systematic review to evaluate the RIC-related adverse effects.

Methods:
We searched PubMed up to June 2017 using the following keywords: “remote ischemic postconditioning”; “remote ischemic preconditioning”; “remote ischemic conditioning” and “remote ischemic preconditioning”. We included any clinical studies with adult subjects. Exclusion criteria were conditioning not performed on remote limbs and not ischemic conditioning. We extracted adverse effects from each study, and summarize the rate of these adverse effects.

Results:
131 studies with 8,895 subjects were included. Six disease conditions were investigated. Only 10 studies reported RIC related adverse effects in the manuscripts while 47 studies stated no RIC-related adverse effects were observed. The highest pressure was 600 mmHg, and lowest pressure was 15 mmHg above systolic blood pressure. The median duration for each session is 5 minutes and the median number of sessions is 4. “Skin petechiae” was the most common adverse effects (50, 0.56%); followed by “discomfort or pain around limbs” (22, 0.24%) and deep-venous thrombosis (2, 0.02%). Sixteen (0.18%) patients did not tolerate the procedure and discontinued from the study.

Conclusions:
Our system review concluded that, in general, RIC was well tolerated and its related adverse events are minor with low incidence rates.
Abstract WP398: Timing of Starting Doacs and Short- and Long-Term Clinical Outcomes for Acute Ischemic Stroke Patients With Nonvalvular Atrial Fibrillation: The Samurai-nvaf Study
Authors: Mizoguchi Tadataka , Takagi Masahito , Sato Shoichiro , Yamagami Hiroshi , Ide Toshihiro , Yoshimoto Takeshi , Shiozawa Masayuki , Todo Kenichi , Yagita Yoshiki , Itabashi Ryo , Terasaki Tadashi , Koga Masatoshi , Toyoda Kazunori
Published: October 2018

Background and Purpose:
Direct oral anticoagulants (DOACs) are widely used for the prevention of ischemic events with non-valvular atrial fibrillation (NVAF). However, it is unknown when DOACs should be started after acute ischemic stroke (AIS) or transient ischemic attack (TIA). The aim of this study was to compare the short- and long-term stroke outcomes between earlier initiation and later initiation of DOACs after onset of AIS.

Methods:
Patients with NVAF who developed AIS/TIA were enrolled from the database of the prospective, multicenter, observational SAMURAI-NVAF study, and they were divided into two groups according to the date of starting DOACs after stroke onset: within 3 days (E-group) and 4 or more days (L-group). The frequency of ischemic event, bleeding, and death up to 2 years was compared.

Result:
DOACs were started as the first oral anticoagulants after AIS/TIA in 499 (42%) of 1192 NVAF patients. Of these, 223 patients were assigned to E-group (74±6 years of age, 78 women) and 276 patients to L-group (75±6 years of age, 101 women). E-group had lower scores of National Institutes of Health Stroke Scale (median 3, interquartile range [IQR] 1-8 vs 5, 2-14; P=0.001) and CHAD
2
S-VASc (median 5, IQR, 4-6 vs 5, 4-6; P=0.04) than L-group. No significant difference was observed in the rate of ischemic events (at 3 months: E 4.0% vs L 2.5%, harzard ratio [HR] 1.59, 95% confidence interval [CI] 0.58-4.48; at 2 years: E 9.4% vs L 10.9%, 0.89, 0.50-1.56), bleeding (at 3 months: E 1.4% vs L 2.2%, HR 0.48, 95% CI 0.10-1.88; at 2 years: E 3.6% vs. L 4.0%, 0.97, 0.36-2.51), and death (at 3 months: E 0.5% vs L 0.4%, HR 1.22, 95% CI 0.05-31.52; at 2 years: E 4.5% vs L 8.7%, 0.57, 0.26-1.17) after multivariable adjustment.

Conclusion:
Early starting of DOACs within 3 days after the onset of AIS/TIA had comparable outcome to later starting of them regarding ischemic events, bleeding, and death.
Abstract WP4: Age and NIHSS score Predict Outcome in Patients With Mild Stroke and Proximal Large Vessel Occlusion
Authors: Narwal Priya , Yaghi Shadi , McTaggart Ryan A , Hemendinger Morgan , Furie Karen , Jayaraman Mahesh V , Cutting Shawna
Published: October 2018

Background:
Current guidelines recommend mechanical thrombectomy for patients with anterior circulation proximal large vessel occlusion (LVO), NIHSS≥ 6, within 6 hours from symptom onset, with a NCCT ASPECTS of 6 or higher. It remains unclear whether patients with NIHSS < 6 and LVO should also undergo mechanical thrombectomy. The benefit of intervention, associated risk and predictors of outcome in this patient population has not been studied. We sought to determine the natural history and predictors of good outcome in patients NIHSS<6 and evidence of LVO who did not undergo mechanical thrombectomy.

Methods:
We abstracted data from our ischemic stroke prospective database and included patients with NIHSS < 6 and presence of proximal large vessel occlusion admitted between January 1
st
, 2015 and April 30
th
, 2017. The outcome, 90-day mRS, was collected via a phone call at 90 days. Patients were divided into two groups: good outcome (90-day mRS 0-1) and poor outcome (90-day mRS 2-6). We compared baseline demographics, treatments, neuroimaging data (ASPECTS score), and vascular imaging findings (location of occlusion, collateral score: poor, good, and excellent) between the two groups. P-value < 0.05 was considered significant.

Results:
A total of 68 patients were identified; 50/68 did not undergo mechanical thrombectomy; out of which only 25/50 (50%) had a good 90-day outcome. Patients with a good outcome were younger (Mean ± SD, 69.3 ±3.2 vs 76 ± 2.2 years of age, p=0.033) and had a lower median admission NIHSS score (3 vs. 4, p=0.026).There was a trend towards good outcome with ICA and M1- MCA occlusion when compared to other locations but this was not statistically significant. Other variables also did not achieve statistical significance.

Conclusion:
Younger age and lower NIHSS predict good functional outcome in patients with LVO and mild deficits. Larger prospective studies are needed to verify our findings and explore the role of mechanical thrombectomy in patients who might be at risk of poor outcome.
Abstract WP400: Magnetic Resonance-Derived Oxygen Extraction Fraction in White Matter Hyperintensities Compared to Normal Appearing White Matter
Authors: Kang Peter , Chen Yasheng , Ford Andria L , An Hongyu , Lee Jin-Moo
Published: October 2018

Introduction:
White matter hyperintensities (WMH), a common neuroradiological feature seen with aging, increases the risk of stroke, dementia, disability and mortality. The underlying pathophysiology leading to WMH is incompletely understood. Here, we examined the role of regional cerebral blood flow (CBF) and oxygen extraction fraction (OEF) in WMH.

Methods:
Subjects with WMH (n=9) and age-matched controls (n=9) were imaged in a 3T MRI Scanner. OEF was obtained using an asymmetric spin echo sequence while CBF was obtained with pseudo-continuous arterial spin labeling. WMH were graded according to Fazekas et al. For tissue-type quantification, CBF and OEF images were segmented to classify whole brain (WB), gray matter (GM), white matter (WM), white matter hyperintensities (WMH), and normal appearing white matter (NAWM).

Results:
CBF and OEF in WB, GM and WM did not differ between cohorts. However, differences emerged when comparing the WMH and NAWM segmented tissues. Specifically, CBF in WMH was less than half that seen in NAWM in the WMH group, and similarly lower than normal WM in controls. Moreover, OEF in WMH was higher compared to NAWM and WM in controls, but this did not reach statistical significance (Table).

Conclusions:
CBF and OEF did not differ between subjects with or without WMH. However, within the WMH group, regions of WMH had significantly lower but not absent CBF and trends towards higher OEF compared to NAWM and normal WM in controls. These data suggest that regions of WMH do not represent irreversibly infarcted tissue, but rather, may be viable tissue under chronic metabolic stress. Increased OEF in WMH may be a marker of salvageable brain tissue; However, additional work is needed to confirm these results.
Abstract WP404: Intestinal Microbiome and Carotid Atherosclerosis
Authors: Spence J David , Bogiatzi Chrysi , Gloor Gregory , Allen-Vercoe Emma , Reid Gregor , Urquhart Bradley
Published: October 2018

Background:
It is increasingly recognized that metabolic products of the intestinal microbiome may have important effects on cardiovascular disease.

Methods:
We studied dietary intake of precursors and plasma levels of toxic metabolic products of the intestinal microbiome in patients at extremes of carotid plaque burden, defined by residual scores (Res) in multiple regression with coronary risk factors: Protected (Res <-2, n = 83), Explained (Res -2 to 2 n = 82) and Unexplained atherosclerosis (Res >2 n = 62). Diet was assessed by a Harvard Food Frequency Questionnaire, and metabolites were measured by ultra-performance liquid chromatography (UPLC) coupled to mass spectrometry (MS). Microbiota were studied by DNA extraction from stool samples; bacteria in each sample were identified and quantitated based upon amplification and sequencing of 16S rRNA variable regions.

Results:
There were no significant differences in Mediterranean diet score, renal function, intake of protein, total choline, carnitine, phenylalanine or tyrosine or the fecal microbiota amongst the groups. However, plasma levels of trimethylamine n-oxide (TMAO), indoxylsulfate, p-cresylsulfate, and phenylacetylglutamine were significantly lower in Protected patients and higher in Unexplained patients (Table 1). Serum creatinine and 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid ( a marker of renal function) were not different among the groups. In this small sample we did not detect differences in the fecal microbiota.

Discussion:
Despite no difference in dietary precursors, renal function or the fecal microbiota, patients protected from atherosclerosis had lower levels and those with unexplained atherosclerosis had higher levels of toxic metabolites of the intestinal microbiome. This suggests their intestinal microbiota are responding differently to dietary intake of precursors from those of patients with explained atherosclerosis.

Conclusion:
This finding raises the potential for manipulation of the intestinal microbiota function through probiotic or prebiotic intake, or replacement of intestinal bacteria, to reduce the risk of carotid atherosclerosis and stroke.
Abstract WP408: Interplay Between Patent Foramen Ovale, Migraine, Stroke and Cerebral Vasomotor Reactivity
Authors: Xasiyev Ferid , Arsava Ethem M , Topcuoglu Mehmet Akif
Published: October 2018

Background:
The first data on influence of patent foramen ovale (PFO) with high-volume right-to-left shunt (RLS) on cerebral vasomotor reactivity (CVMR) in migraineurs are presented. In addition, immediate effect of air microbubbles (MB), injected for the bubble TCD test, on CVMR has been determined.

Methods:
Breath holding index (BHI, vasodilatory capacity-vdCVMR) and percent decrease during hyperventilation (vasoconstriction capacity-vcCVMR) tests were performed before and after bubble TCD test in bilateral middle and posterior cerebral arteries (MCA and PCA) in 38 migraine (19 with aura) and 18 control patients; 26 patients had large PFO while others had no RLS. Subjects with mild/moderate RLS were not enrolled.

Results:
Presence of PFO was related to a significant decrease of BHI recorded in MCA (1.43±0.39 vs. 1.04±0.67, p=0.032) and marginal reduction of PCA BHI (1.01±0.39 vs. 1.25±0.46, p=0.090) in migraineurs. vdCVMR reduction was more prominent in the contralateral side (to pain). PCA BHI significantly decreased after agitated saline injection in the bubble test. Decrease was greater in patients with PFO (from 1.03±0.40 to 0.78±0.38, p=0.007) compared those without PFO (from 1.15±0.42 to 0.91±0.45, p=0.014). The decrease was prominent in subjects with both migraine and PFO (from 1.01±0.40 to 0.76±0.42, p=0.023). No significant difference was seen in BHI with MCA after bubble injection. Bubble passage correlated to occurrence of headache after test. No difference was noted for the parameters of vcCVMR in subjects with/without PFO. Patients with FLAIR-determined silent ischemic lesion(s) had no difference in VMR before bubble test and VMR response to aerated bubble passage.

Conclusions:
The presence of PFO with high grade RLS is associated with reduced vasodilatory CVMR in migraineurs. Further decrease of vdCVMR of PCA upon MBs passage may support the mechanism of " facilitation with subclinical cerebral ischemia caused by microembolism", one of the hypotheses explaining the onset of migraine.
Abstract WP41: Endovascular Therapy versus Intravenous Thrombolysis in Cervical Artery Dissection Ischemic Stroke - A Systematic Review and Meta-analysis and Results From the Swiss Registry
Authors: Traenka Christopher , Jung Simon , Gralla Jan , Kurmann Rebekka , Stippich Christoph , Goeggel Simonetti Barbara , Gensicke Henrik , Mueller Hubertus , Lovblad Karl , Eskandari Ashraf , Puccinelli Francesco , Vehoff Jochen , Weber Johannes , Wegener Susanne , Steiner Levke , Kaegi Georg , Luft Andreas , Sztajzel Roman , Fischer Urs , Bonati Leo H , Peters Nils , Lyrer Philippe A , Arnold Marcel , Engelter Stefan
Published: October 2018

Background:
Data on endovascular therapy (EVT) in patients with stroke attributable to CeAD is scarce. We performed a systematic review and meta-analysis of all studies comparing EVT to intravenous thrombolysis (IVT) in CeAD-patients and compared EVT to IVT with regard to 3-month outcome and complications. Additionally, we included data of IVT-/EVT-treated CeAD-patients from a Swiss multicenter IVT-/EVT registry based cohort study.

Methods:
We systematically searched the pubmed® database to identify all existing studies comparing IVT to EVT in CeAD-patients. Studies were eligible if IVT-treated CeAD- patients were compared to EVT-treated patients, and 3-month outcomes were reported as modified Rankin Scale (mRS) score. Outcome measures in this study were favorable 3-month outcome (i.e. mRS 0-2), excellent 3-month outcome (i.e. mRS 0-1), symptomatic intracranial hemorrhage (sICH) and death. Additionally, in a Swiss multicenter IVT-/EVT registry based cohort-study (SWISS) we identified all consecutive patients with ischemic stroke attributable to CeAD and included outcome data of these patients in our analyses. In a meta-analysis across all studies, we compared EVT to IVT with regard to primary and secondary outcome measures using a fixed-effect Mantel-Haenszel model.

Results:
The literature search yielded 388 results. We identified 7 eligible studies for a systematic comparison of EVT versus IVT. Data on 62 patients from the SWISS cohort were included as an additional study. In total, we compared EVT (n=102) versus IVT (n=110) in 212 CeAD-patients. With regard to the occurrence of mRS 0-2, there was no significant difference between both treatment groups (OR 1.04 (95% CI 0.57-1.88)). Separate Data on mRS 0-1 was available in 5 studies (OR 0.88 (95% CI 0.39-2.00)). There was no difference between groups with regard to death at 3 months (OR 0.66 (0.22-1.94)) which was separately reported in 6 studies. For sICH there were too few data (n=5 patients) available for meta-analysis.

Conclusion:
In this systematic review and meta-analysis of all existing studies comparing EVT to IVT in CeAD patients there was no clear signal of superiority of EVT. Further investigation of EVT with up-to-date devices is warranted.
Abstract WP413: White Matter Tract Disruption on Diffusor Tensor Imaging is Associated With Serum Ceramides in a Healthy Middle-Aged High Risk Population
Authors: Nyquist Paul A , Hannawi Yousef , Yanek Lisa R , Kral Brian G , Becker Lewis C , Vaidya Dhananjay , Haughey Norman , Becker Diane M. Becker M
Published: October 2018

Introduction:
White matter tract disruption (WMTD) on Diffusion Tensor Imaging (DTI) may reflect early axonal disruption and tract injury and identify risk for dementia. Brain ceramides play a role in processes also associated with dementia risk. We hypothesized that circulating ceramide levels might serve as biomarkers of WMTD in a population at high risk for early vascular disease. We studied six ceramides and WMTD using fractional anisotropy (FA) on DTI in healthy relatives of patients with early coronary disease. We have previously shown a high prevalence of white matter hyperintensities (WMH) and significant associations between WMH volumes, FA, and lower cognitive function in healthy relatives.

Methods:
DTI was acquired with Phillips 3T MRI. FA was measured for 181 regions of the segmented brain using Eve atlas. 48 relevant regions with susceptibility for WMTD were analyzed. Serum ceramides were measured using high performance liquid chromatography. Spearman correlations and GEE linear regression analyses (adjusted for age, sex, race, education and family relatedness) were used. We set the significance level to meet the Bonferroni threshold of 0.00017 (0.05 / 48 regions/6 ceramides).

Results:
Subjects, N=112, had a mean age of 49± 11 years; education 14 ± 3 years; 49% male; 39% African American, 61% European American). Serum levels for ceramides designated C18:0, C20:0, and C22:0 were significantly negatively correlated with FA in the right fornix (C18:0, R=-0.40, p=1.3 x10
-5
, C20:0, R=-0.41, p= 6.1 x 10
-6
, C22:0, R=-0.33, p=4.3 x10
-4
). C18:0 was negatively correlated with the left genu of corpus callosum (R=-0.39, p=2.6 x10
-5
) and right body of corpus callosum (R=-0.31, p=8.5 x10
-4
). An additional ceramide, C24:0, was correlated with both sides of the posterior limb of internal capsule (left R=0.34, p=2.5 x10
-4
; right R=0.34, p=2.8 x10
-4
). All ceramide-FA associations were significant (p<0.05) after fully adjusted GEE regression.

Conclusions:
We show a robust relationship between serum ceramides and WMTD using FA in a middle-aged, cognitively intact at-risk population enriched for early WMH. Thus, serum ceramide levels may reflect subtle alterations in white matter tract microstructure at an early preclinical stage. 
Abstract WP414: Total Burden Of Magnetic Resonance Imaging Load Of Cerebral Small Vessel Disease Features And Outcome Of Acute Ischemic Stroke
Authors: Sovich Samantha , Tariq Areej , Gurcan Metin N , Torbey Michel T , Hannawi Yousef
Published: October 2018

Introduction:
Age is a major risk factor for Cerebral Small Vessel Disease (CSVD) and poor functional outcome following acute ischemic stroke (AIS). Recently, white matter hyperintensity (WMH), a surrogate for CSVD has been associated with AIS poor functional outcome. We aimed to investigate the effect of the total MRI load of CSVD features on AIS functional outcome and their relationship to age.

Methods:
Patients presenting with AIS were prospectively recruited. Baseline characteristics, in-hospital complications, acute therapies and discharge dispositions were collected. Total CSVD disease burden (WMH, lacunes, microbleed (MB) and enlarged perivascular space (PVS)) was measured on the first MRI within 24 hour of hospital admission using (0-4) scale according to Staals et al, Neurology 2014. Univariate analysis was completed using t-test, Mann-Whitney Rank Sum test, Chi square test or Spearman correlation as appropriate. Multivariate logistic regression analysis was performed to adjust for the effect of age, stroke volume and CSVD score on the functional outcome of AIS.

Results:
99 subjects with AIS were analyzed (age 65.4±13.7, 52.5% females). 68.4% of patients had favorable discharge outcome (home or acute rehabilitation). CSVD features were present in the cohort as the following: 41.2% had lacunes, 26.4% had MBs, 70.1% had more than 10 PVS in the basal ganglia and 42.4% had Fazekas score of periventricular WMH of 3 or deep WMH of 2 or above. Total CSVD score was 1.6±1.4, and correlated with age (p=0.0015) but not with stroke volume (p=0.71). Unfavorable stroke outcome was associated with higher stroke volume, CSVD score and age (p =0.0005, 0.003 and 0.012, respectively). This relationship remained significant in multivariate analysis for CSVD (p=0.008) and stroke volume (p=0.004) but not for age (p=0.72).

Conclusions:
CSVD burden on MRI is associated with worse functional outcome of AIS. This effect appears to be independent of the effect of age on AIS outcome. These results need to be validated in larger cohorts.
Abstract WP416: Comparison of Ex-vivo Human Leptomeningeal Arteriole Function in Cognitively Normal and Dementia Disorders From Rapid Autopsy Brain Donors
Authors: Madrigal Calvin , Truran Seth , Karamanova Nina , Serrano Geidy , Madine Jillian , Davies Hannah , Beach Thomas , Migrino Raymond Q
Published: October 2018

Vascular dysfunction is increasingly recognized in the pathophysiology of dementia disorders such as Alzheimer’s disease (AD). We showed that exposure to β-amyloid (Aβ) and medin (aging-associated amyloid) cause cerebrovascular endothelial dysfunction which may be involved with cognitive dysfunction. We

aim

to test the hypotheses that patients with AD, mild cognitive impairment (MCI) and vascular dementia (VD) differ in cerebrovascular arteriole function and have worse vascular response to amyloid proteins when compared to cognitively normal (CN) patients.

Methods:
Under a Brain Donation Rapid Autopsy Program, leptomeningeal arterioles were isolated from 44 donors (89.6±1.4 years), cannulated, pressurized and baseline endothelium-dependent dilation (EDD, acetylcholine max 10
-4
M) and smooth muscle dilation (SMD, papaverine or DETA-Nonoate) were measured and compared among CN, MCI, AD and VD subjects. % change from baseline responses were also measured following 1 hour exposure to Aβ42 (0.5 or 2 μM) or medin (5 μM).

Results:
There was no difference in baseline EDD and SMD among the groups (Fig. A,B). Overall, Aβ caused reduction in EDD (46.2±3.8 vs. 75.3±3.5% baseline, p<0.001) and SMD (83.6±2.8 vs. 90.7±2.6% baseline, p=0.02). Medin caused similar reduction in EDD (35.7±4.7 vs. 77.5±4% baseline, p<0.001) and SMD (70.9±5.4 vs. 89.3±3% baseline, p=0.006). Dilator responses to Aβ and medin did not differ among the groups (Fig. C-F).

Conclusions:
Contrary to our hypotheses, leptomeningeal arteriole function did not differ among CN, MCI, AD and VD patients. Aβ and medin caused endothelium and smooth muscle dysfunction, but the degree of dysfunction was not different among the groups. The results may point to the importance of

duration/degree of exposure to vasculogenic amyloid proteins

(the ‘milieu’) rather than

intrinsic differences in arteriole properties

in accounting for vascular dysfunction leading to cognitive dysfunction in dementia disorders.
Abstract WP423: Adiponectin and Components of Metabolic Syndrome are Associated With Cortical Thickness: The Northern Manhattan Study
Authors: Caunca Michelle R , Simonetto Marialaura , Ng-Reyes Michelle , Guerrero Daysi , Alperin Noam , Lee Sang H , Bagci Ahmet M , Elkind Mitchell S , Sacco Ralph L , Wright Clinton B , Rundek Tatjana
Published: October 2018

Objective:
Examine the association of adiponectin and metabolic syndrome components with measures of global and lobar cortical thickness.

Background:
Metabolic syndrome has been associated with structural brain changes, but the relationship of adiponectin and cortical thickness is understudied.

Methods:
The Northern Manhattan Study MRI Sub-Study is a mostly Hispanic, stroke-free, prospective cohort study of older adults. Cortical thickness (mm) was obtained from T1-weighted brain MRIs using the publically-available Freesurfer software. Regional cortical thickness metrics were averaged to obtain mean lobar cortical thickness. Adiponectin (μg/mL) was measured at baseline (1993-2001). Metabolic syndrome components were measured at MRI Sub-Study baseline (2003-2008). We estimated the cross-sectional associations of adiponectin (per 1 SD) and metabolic syndrome components with global and lobar cortical thickness (per 1 SD) using multivariable linear regression models adjusted for sociodemographic factors, APOE ε4 allele presence, and health-related behaviors. All hypothesis testing was two-sided with an alpha level of 5%.

Results:
Freesurfer data were available in 947 participants (mean±SD age=70±9 years, 63% women, 66% Hispanics, 16% black, and 15% white). Global cortical thickness was normally distributed (mean±SD = 2.3±0.1mm). In fully adjusted models, 1 SD (4.9μg/mL) increase in adiponectin was associated with smaller overall (β [95%CI] = -0.07 [-0.14, -0.0002]) and parietal cortical thickness (β [95%CI] = -0.08 [-0.03, -0.0002]). Greater blood glucose levels significantly associated with smaller occipital cortical thickness (β [95%CI] = -0.003 [-0.006, -0.0007]). Greater waist circumference was significantly associated with smaller frontal cortical thickness (β [95%CI] = -0.02 [-0.04, -0.0007]). Neither blood pressure (systolic and diastolic) nor cholesterol (total, HDL-C, and LDL-C) were associated with global or regional cortical thickness.

Conclusions:
There was heterogeneity in the cross-sectional associations between adiponectin, metabolic syndrome components, and regional cortical thickness. Further studies are needed to explore the temporal relationship between risk factors and cortical thinning.
Abstract WP425: Influence of Medication on Presentation in Patients With Cavernous Malformation
Authors: Flemming Kelly , Lanzino Giuseppe , Brown Robert D
Published: October 2018

Background:
There are concerns about use of certain medications in patients with cavernous malformations (CM) being deleterious such as antithrombotics. In addition, there are select medications such as statins, vitamin D, and NSAIDs which theoretically may have a positive effect on endothelial leakiness. We aimed to determine whether certain medications taken prior to the diagnosis of CM influenced the presentation to medical attention.

Methods:
We established a prospective cohort of patients with clinically diagnosed CM in 2015. Patients are interviewed at inception and clinical records reviewed. Specifically, several medications are recorded including the use of: antithrombotics, NSAIDs, estrogen, Vitamin E, Vitamin D, SSRI, statin, and multivitamin. Patients are followed prospectively. Data continues to be collected annually on outcome events (bleeding) and ongoing medication use.

Results:
These results are on the first 103 patients entered into the database. Sixty-four (62.1%) patients are male and the average age at diagnosis is 39.1 years. Sixty-three (61.1%) presented with symptoms and 40 (38.9%) were incidental findings at first diagnosis. Patients taking NSAIDs (p=0.0468), Vitamin D (p=0.035), and statins (p=0.0163) were more likely to present with an incidental CM compared to those who presented symptomatically (hemorrhage, seizure or focal neurologic deficit). There was no significant difference in symptomatic vs. asymptomatic presentation in patients taking estrogens, warfarin, clopidogrel, SSRI, or vitamin E prior to presentation.

Conclusion:
This data supports the theoretic role of vitamin D, NSAIDS, and statin use in stabilization of endothelial permeability. Ongoing data collection and prospective follow up will allow us to determine if ongoing use of these medications plays a role in reducing risk of future hemorrhage.
Abstract WP427: Health-related Quality of Life Measures in Familial Cerebral Cavernous Malformation Patients
Authors: DeKay Keva C , Guo Diana , Yan Kimberly , Nelson Jeffrey , McCulloch Charles E , Akers Amy , Bartlett Mary Rose , Hart Blaine , Kalani Yashar , Harrigan Mary , Zabramski Joseph , Morrison Leslie , Kim Helen
Published: October 2018

Background:
Patient-reported quality of life (QoL) using standardized tools have been proposed as outcome measures in clinical trials. The NeuroQoL scale has been evaluated in patients with common neurological disorders (e.g., ischemic stroke, epilepsy, ALS, and Parkinson’s), but has not been applied to familial cerebral cavernous malformation (FCCM). FCCM is typically characterized by multiple brain lesions that can cause clinical symptoms (hemorrhages, seizures, headaches, neurological deficits) and affect QoL. The purpose of this study was to summarize NeuroQoL domain scores in FCCM patients.

Methods:
NeuroQoL short forms covering 12 QoL domains (Figure) were completed by 50 FCCM adults enrolled in the Brain Vascular Malformation Consortium CCM Project. Raw scores summing responses in each domain were converted to T-scores, which are standardized to general (8 domains) or clinical (4 domains) reference populations with mean of 50 and standard deviation of 10. One-sample t-tests were used to determine whether mean T-scores were significantly different from 50 (p<0.05).

Results:
We observed significant differences between FCCM and the reference populations on several domains (Figure). Compared to the general reference population, FCCM patients were more likely to have higher positive affect (56, p<0.001) and less depression (55, p<0.001), but lower social satisfaction (48, p=0.032). Compared to the clinical reference population, FCCM patients reported significantly less stigma (61, p<0.001) and less fatigue (54, p=0.018).

Conclusion:
FCCM patients differed from the reference populations on several NeuroQoL domains, including positive affect, depression, stigma, fatigue and social satisfaction. Further studies are needed to understand the effect of clinical symptoms on NeuroQoL domains in FCCM.