bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP346: Frequency of Convexal Subarachnoid Hemorrhage in the General Population
Authors: Yost Micah D , Arnold Fiebelkorn Catherine , Vemuri Prashanthi , Rabinstein Alejandro , Aakre Jeremiah , Przybelski Scott , Flemming Kelly , Brown Robert , Klaas James , Kantarci Kejal , Mielke Michelle , Knopman David , Jack Clifford , Petersen Ronald , Graff-Radford Jonathan
Published: October 2018

Background:
Non-traumatic convexal subarachnoid hemorrhages (cSAH) in the elderly can be a manifestation of cerebral amyloid angiopathy (CAA) and predict future intracerebral hemorrhage risk. The frequency of cSAH in the elderly population is unknown. Our objective was to determine the frequency of convexal subarachnoid hemorrhage in a population-based study among individuals who underwent amyloid PET imaging.

Methods:
Between 11/29/2004 and 3/11/2017 there were 1,687 participants ages 50-years and older in the population-based Mayo Clinic Study of Aging (MCSA) with Pittsburgh compound B (PiB) PET imaging. All intracerebral hemorrhages among participants were identified utilizing the Rochester Epidemiology Project’s records linkage system, and records and images were reviewed to identify those with both symptomatic and asymptomatic convexal subarachnoid hemorrhage. Neuroimaging characteristics, demographics, medications, and ApoE genotype were recorded.

Results:
Four (0.23%) cSAHs were identified among the individuals who underwent PiB PET imaging. Three were women and median age was 73 (range: 67-84). cSAH occurred in the following locations: right frontal (3), and right parieto-occipital (1). Two went on to develop a lobar intracerebral hemorrhage at a median of 4.75 years after cSAH. Coexisting cerebral microbleeds were identified in one case. The APOE allele combinations of the four participants were: 3/3, 3/3, 2/2, and 2/3. On PiB PET imaging, the median SUVR was 1.81 (range: 1.38-2.34).

Conclusion:
cSAH is a relatively rare manifestation of CAA occurring in less than 1% of the general population, but may represent a subset with a high risk of future intracerebral hemorrhage. Half of the participants with cSAH had an APOE e2 allele.
Abstract WP347: Cardioembolic Risk and Recovery After Anticoagulation-Related Intracerebral Hemorrhage
Authors: Biffi Alessandro , Murphy Meredith P , Kuramatsu Joji B , Leasure Audrey , Kamel Hooman , Kourkoulis Christina , Schwab Kristin , Ayres Alison M , Elm Jordan , Gurol M. Edip , Greenberg Steven M , Viswanathan Anand , Anderson Christopher D , Schwab Stefan , Rosand Jonathan , Testai Fernando D , Woo Daniel , Huttner Hagen B , Sheth Kevin N
Published: October 2018

Introduction:
Oral Anticoagulation Treatment (OAT) resumption remains an unresolved question in Intracerebral Hemorrhage (ICH) care. Previous studies focused on the effects of OAT resumption on recurrent stroke.

Hypothesis:
OAT resumption is associated with increased likelihood of functional recovery after ICH, even in the absence of symptomatic stroke recurrence.

Methods:
We analyzed data for 614 ICH survivors on OAT at time of stroke, who did not experience mortality or recurrent stroke during follow-up, enrolled in three observational studies: 1) the RETRACE study (n=317); 2) a longitudinal ICH study conducted in Boston, USA (n=166); 3) the ERICH study (n=131). We conducted univariable and multivariable analyses of associations between cardioembolic risk (defined by CHA
2
DS
2
-VASc score), OAT resumption, and functional recovery after ICH, defined as ≥ 1 point decrease in modified Rankin Scale (mRS) score at one year post-ICH vs. at discharge.

Results:
Among 614 participants, 153 (25%) resumed OAT. Individuals resuming OAT differed from those who did not only by higher CHA
2
DS
2
-VASc score (p=0.011). CHA
2
DS
2
-VASc score was associated with decreased likelihood of functional recovery at 1 year after ICH (Odds Ratio [OR] = 0.73 per 1 point increase, 95% Confidence Interval [CI] = 0.62-0.88, p <0.001). OAT resumption was independently associated with higher likelihood of recovery, regardless of CHA
2
DS
2
-VASc score (OR=2.93, 95% CI = 1.25-4.61, p=0.001). Interaction analyses (Figure) clarified that subjects with higher CHA
2
DS
2
-VASc score benefited more from OAT resumption in terms of functional recovery (OR = 1.69, 95% CI = 1.20-2.38, p=0.003).

Conclusions:
Increasing cardioembolic risk associated with decreased likelihood of functional recovery after ICH. This effect was mitigated by OAT resumption, with greater benefit seen for subjects at high cardioembolic risk. These findings strongly support exploring recovery outcomes in future studies of OAT-ICH.
Abstract WP349: How Long Do I Have to Stay for a TIA?
Authors: Wolber Nicole E , Paletz Laurie , Robertson Betty , Steiner Nili , Levesque Denise , Guerra Sonia , Nunez Nancy , Gargano Jennifer
Published: October 2018

Background:
It is estimated that in the US, between 200 and 500 thousand TIA’s are reported each year. Half of those patients never report it to their physician. TIA’s once regarded as benign are now recognized as an emergent warning sign of underlying disease and possible impending stroke. By the time many of these patients get to Cedars Sinai, they are asymptomatic and can’t understand the need for a long hospital admission. In 2011 we started our TIA program that enabled us to work up a patient and potentially discharge them from the hospital in 23 hours. The program was a success and patient length of stay decreased dramatically. In 2013, we noted that the length of stay was gradually increasing again. Re-Education efforts for staff about the TIA program proved ineffective, and made only a slight decrease in length of stay. We noted that TIA patients could potentially be admitted anywhere in the hospital and many were not being captured in the system. We needed a better, more consistent solution. We decided to admit and cohort all TIA patients to the Medical Observation Unit (MOU).

Researchable Questions:
Would cohorting all TIA patients in the Medical Observation Unit show a consistent decrease in length of stay? Is there a benefit to putting all TIA patients in the Medical Observation Unit?

Methods:
We began extensive education with staff and management of the MOU. We educated on the importance of monitoring asymptomatic TIA patients, testing specific to these patients, and how we smoothly expedite them through the system under CODE TIA. In April 2015 all TIA patients were admitted into the MOU

Conclusion:
Cohorting TIA patients to the MOU has proven to be a success. Prior to the initiation of the cohorting process, TIA length of stay was 1.9 days. The current length of stay for a TIA patient in the MOU is 0.87 days. This has been dramatic and consistent decrease for almost two years. We also noted that several Code Brains have been called from this unit as the nurses are hypervigilant at monitoring these asymptomatic patients. Several of these patients have been quickly treated with tPA and have had only small or averted strokes because of the quick response from MOU nurses.
Abstract WP352: Self-Releasing Safety Belt Leads to Falls Reduction on Acute Stroke Unit
Authors: Sleva Jonathan , Coyle Jennifer , Casey Stephanie , Szlachta Carolyn , Harley Caitlin , Kuruvilla Elizabeth
Published: October 2018

Intro:
In 2015, a 21-bed acute stroke unit within a Comprehensive Stroke Center at an academic medical facility experienced a stark increase in their falls rate. A monthly average of 4.58 falls per 1,000 patient days was recorded for 2015, which was an increase over the two previous years.

Methods:
Various options were discussed to address the high rate of falls based on the unit population and the types of falls. After discovering an increase in falls from the bedside chair it was decided to implement use of a self-releasing safety belt when the patients were out of bed to the chair. The belts incorporated an alarm tied into the call bell system that would be triggered when released. This allowed for an additional layer of alarm to elicit a staff response to the room prior to a patient falling. Nursing and therapy staffs were educated on the utilization of these self-releasing belts when assisting any patient from bed to chair. Every patient admitted with the diagnosis of stroke utilized these belts while out of bed to the chair, even those who were deemed fully independent.

Results:
After implementation, the average fall per 1,000 patient days’ rate decreased from 4.58 falls to 3.89 falls per month. The total numbers of falls also decreased from 28 in 2015 to 20 in 2016. Falls from the chair, specifically, decreased from 11 in 2015 to 5 in 2016, representing a fifty percent decrease in falls from the chair with use of the self-releasing seatbelt.

Conclusions:
Overall, the falls rate decreased, and the falls specifically from the chair decreased. Data collected reflects all falls on the unit during the period in question and was not limited to patients using the self-releasing safety belts or falls from the chair. The next steps will be to ensure this practice is utilized uniformly and to evaluate similar methods to reduce falls from the bed and drive our rates down to zero falls per month.
Abstract WP353: Decreasing "Door to Admission" Times for Intravenous tPA Treated Patients: A Single Comprehensive Stroke Center Experience
Authors: Girotra Tarun , Raper Lee Anne , Schultz Lonni , Alsrouji Owais , Katramados Angelos , Cohen Lisa , Brady Megan , Miller Daniel J
Published: October 2018

Introduction:
AHA’s Get with The Guidelines (GTWG) initiative has recommended “door to admission” time for patients receiving IV tPA to be <3 hours. In large tertiary hospitals like ours, complicated administrative steps and coordination required to admit patients often leads to delays. There has been a paucity of studies aiming to streamline this process for patients treated with IV tPA.

Aim:
To assess whether having a dedicated rapid response team (RRT) RN within the ED to coordinate care of patients receiving IV tPA reduces “door to admission” times.

Methods:
A policy of notifying RRT of all patients eligible for IV tPA was implemented in the ED. The responsibility of RRT was to coordinate care between neurology resident, ED nurse, acute stroke unit (ASU) charge nurse and admissions office to ensure timely completion of steps required for admission. “Door to admission” times were collected prospectively for 3 months before and after intervention. The compliance of recording neuro checks and vital signs per AHA guidelines for post tPA care were also measured. Wilcoxon two sample test was used to analyze time variables and compliance rates.

Results:
The post intervention group had significantly decreased “door to admission” and “bolus to admission” times (see table). Also, significantly fewer patients had >1 vital signs checks miss in post-intervention group (6% vs 38%; p=0.033). There was no significant increase in the compliance rate of neuro checks.

Discussion:
By adding RRT in coordination of care for IV tPA patients in the ED, we were able to drastically reduce our door to admission times. The improvement was because of faster placement and prioritized processing of the admission orders. RRT acted as a “control center” relaying vital information to admission office and ASU charge nurse. This also freed ED RN to improve compliance rate of recording vital signs in IV tPA patients. Similar interventions can be used by other centers to decrease their “door to admission” times.
Abstract WP356: Impact of a Designed Acute Stroke Nursing Management Protocol on Nurse’s Knowledge and Practices
Authors: Zidan Samah , Elfeky Hanaa , Yossif Warda , Abd Allah Foad
Published: October 2018

Background:
Stroke is a major public health problem worldwide and in Egypt. It is a life-threatening disease that requires early recognition, management and collaboration of all members of the health care team. Critical care nurses play an important role in all phases of care for stroke patients.

Aim:
study the impact of a designed acute stroke nursing management protocol on critical care nurses’ knowledge and practices.

Hypothesis:
The mean post-test total knowledge and practices scores of critical care nurses who are exposed to the designed nursing management protocol of care will be higher than their mean pre-test scores.

Sample:
A convenience sample of (30) nurses.

Design:
A quasi-experimental, single group interrupted time series design was utilized.

Tools:
tool (1): Nurses Knowledge Assessment Questionnaire (2): Pre /post observational checklists. Critical care nurses were assessed three times: before implementing the protocol of care, immediately after implementing the protocol of care, and two months after.

Results:
the current study revealed that most of the studied sample (80%) were female in the middle age groups (X= 30.16, SD =7.71), and the total mean knowledge scores in the second and third assessment times (X= 70.47, SD =6.27, X= 66.67, SD= 8.1) respectively, improved as compared to the first assessment time (X= 24.23, SD= 11.24) with a significant statistical difference between the three assessment times (F= 246.344, P ≤ 0.05). The total mean practices scores in the second assessment and third assessment times (X= 45.90, SD= 5.02, X= 39.87, SD= 4.54) respectively, was higher than the total mean practices scores in the first assessment (X= 22.10, SD= 7.42) with a significant statistical differences between the three assessments (F= 131.913, P ≤ 0.05) . A significant statistical differences between the three assessments was found regarding utilization of NIHSS and GCS (F= 420.310, 123.189, P ≤ 0.05).

Conclusion:
effectiveness of implementing the protocol of care where nurses’ knowledge and practices improved significantly as compared before implementing the protocol of care. So, the study recommends continuous training and education for nurses to improve their knowledge and practices with availability of Arabic references.
Abstract WP359: Enteral Tube Feeding Propensity Score for Acute Stroke Patients
Authors: Dalfior Luiz , Veronezi Augusto Geovanna , Oliveira Luiz Fernando , Honorato Maira , Nunes Patricia , Letícia de Freitas Julian , Nascimento Oliveira Pablo , Ferreira Machado Michel , Guimarães Rocha Maria Sheila
Published: October 2018

Background:
Stroke is the most frequent cause of neurogenic oropharyngeal dysphagia. Its frequency is greater than 50% in the acute phase. The early clinical evaluation of swallowing disorders can help define approaches and avoid oral feeding, which may be detrimental to the patient. The aim of this study was to identify predictive clinical factors associated with enteral tube feeding (ETF) in acute stroke patients to develop an ETF predictive score.

Methods:
The medical records of 1104 acute ischemic stroke patients from our prospective stroke database were reviewed. Clinical factors as age, sex, blood pressure, glycemia, NIHSS score, Glasgow coma scale, previous Rankin, localization, and classification of acute stroke, and comorbidity index were analyzed. Logistic multivariate regression was used to identify perfect predictors of early ETF placement. The sample was randomly divided into two samples (30 and 70% of the sample) to proceed the internal score validation.

Results:
1104 patients were enrolled. Mean age was 65.9 years old (SD 13), male patients were 51.7%, mean Glasgow score was 13.9 (SD 1.9), NIHSS at admission was 7.2 (SD 5.7), mean ASPECT score was 9.3 (1.6). Multivariate logistic regression disclosed age (odds ratio [OR] 1.02; CI 95% 1.00-1.03, p=0.005), initial NIHSS (OR 1.15; CI 95% 1.11-1.19, p<0.001) and NIHSS dysarthria subitem (OR 1.76; CI 95% 1.36-2.37, p<0.001) as independent predictive variables. The EFT propensity score was constructed based on these variable. A score equal or above four correctly classified 75% of patients (sensitivity = 67%, specificity = 79%). A ROC curve (AUC = 0.78, CI 0.75 - 0.81; p = 0.015) was constructed taking the formal phonoaudiological evaluation as gold-standard.

Discussion:
The ETF score allows us to quickly identify and indicate the use of ETF in acute stroke patients avoiding delay in starting enteral feeding and reducing the risk of bronchoaspiration, morbidity, and mortality due to pneumonia. Besides, the ETF score might optimize the patient care in hospitals where the speech therapist is not always available. Conclusion: Combining data from age, NIHSS at admission and the dysarthria subitem could be a strong and useful predictor to evaluate and decide about ETF in acute stroke patients.
Abstract WP360: Use of a Care and Communication Bundle Can Improve Resource Utilization and Timeliness of Palliative Care for Severe Stroke Patients in the Neuroscience ICU
Authors: Toumbs Randi R , Taylor Tracey L , Cossey Tiffany D , Choi HuiMahn A
Published: October 2018

Background:
Severe stroke patients have immediate palliative care (PC) needs and communication between families and clinical teams has been identified as a gap in PC delivery. Delays in care planning can increase length of stay (LOS) and cost of care (COC) which decreases efficient resource utilization.

Purpose:
The purpose of this quality improvement project is to evaluate whether standardizing the communication process between families and treatment teams using a communication bundle validated in the medical ICU improves LOS, COC, and time to PC consultation in severe stroke patients in a neuroscience ICU.

Methods:
The Care and Communication Bundle (CCB) was prospectively implemented in 22 consecutive patients from February-April 2017 and compared to a control arm of 22 consecutive patients via retrospective chart review from February-April 2016. Improvement in resource utilization was defined as a decrease in LOS and COC. Patients with a primary diagnosis of ischemic or hemorrhagic stroke, NIHSS score of ≥ 15, and an expected ICU LOS of ≥ 5 days were included. Descriptive statistics were analyzed using Chi Square, Mann-Whitney
U
, or
t-
test where appropriate. Significance was set at
p
<0.05.

Results:
In the CCB group versus the control group, the median ICU LOS (2 vs 5.5 days,
p
=0.04), median hospital LOS (4 vs 9 days,
p
=0.02), and ICU COC ($21,118 vs $68,634,
p
=<0.01) were significantly lower. Documentation of code status (18 vs 9 patients,
p
=<0.01), advanced directives (21 vs 6 patients,
p
=<0.01), and family meetings (20 vs 13 patients,
p
=0.02) were significantly higher in the CCB group. The CCB group received earlier PC consults (1.5 vs 3.5 days,
p
=0.07).

Conclusions:
Standardizing communication between families and treatment teams significantly improved resource utilization and improved timeliness of PC delivery to severe stroke patients. Larger prospective studies of the CCB in severe stroke patients and within other neuroscience ICU populations are needed.
Abstract WP367: Evaluation of Stoke Severity Using NIHSS as a Predictor for Readmissions in a Veteran Population
Authors: Olatunji Amina H , Haig Haig , Sahi Gurpreet , Cole Bradley , Davies Marie , Gogineni Hyma
Published: October 2018

Background and Issues:
Stroke is a leading cause of death and results in readmissions up to 20-27% within the first 1 year. The National Institute of Health Stroke Scale (NIHSS) is a score used to quantify stroke severity (higher being more severe). Mixed data exist as to whether this score can predict readmission.

Purpose:
The purpose of this study was to assess the NIHSS score as a predictor for readmission rates and whether higher NIHSS scores are associated with 30-day readmission rates.

Methods:
This IRB-approved retrospective chart review included patients admitted to the VA Loma Linda Healthcare System for ischemic stroke, hemorrhagic stroke, or a transient ischemic attack from June 2015-July 2016. Patients were excluded if they had other neurologic diagnoses or if care was transferred to another institution. Data collected included demographics, NIHSS score at index stroke, comorbidities, time interval to readmission, and readmission diagnosis. Statistical analyses included Student’s T-test and Fisher’s exact for assessing NIHSS as a continuous and categorical (mild vs moderate/severe) predictor respectively.

Results:
Among 72 stroke patients, 16 patients were readmitted. There was no difference in the mean NIHSS of readmitted vs. non-readmitted patients (2.56 (2.71) vs 2.55(2.97)). Patients with moderate/severe NIHSS had higher readmission rates compared to those with mild NIHSS, but this was not statistical significant (40% vs. 21%; P=0.31). However, patients readmitted within 30 days had a significantly higher mean NIHSS than those readmitted >30 days (3.58 vs 1.53; 95% CI=0.52-4.12; P=0.014). There was no significance in readmission based on discharge disposition or administration of tissue plasminogen activator.

Conclusions:
Patients readmitted within 30 days of index stroke had higher NIHSS scores and therefore more severe stroke symptoms. There was a trend that patients with moderate/severe NIHSS scores were more likely to be readmitted, but this was not significant. Collectively these finding indicate NIHSS may be important for predicting readmissions.
Abstract WP372: Screening For Large Vessel Occlusion - Comparing the Accuracies of the VAN Screening Tool and NIHSS
Authors: Patterson Michele , Moore Tracy , Birnbaum Lee , Behrouz Reza , Cline Beth
Published: October 2018

Background:
Our five-hospital Comprehensive Stroke Program utilizes a large vessel occlusion (LVO) triage that includes NIHSS ≥ 10 and last known well (LKW) < 6 hours. It was determined that a more effective triage for patients with LVO was needed. The vision, aphasia, and neglect (VAN) screening tool has been validated as an effective tool to assess for LVO. An NIHSS ≥ 6 has also been shown to have reasonable accuracy.

Purpose:
To compare the accuracies of the VAN screening tool and NIHSS ≥ 6 for identification of LVO in our emergency departments.

Methods:
A retrospective chart review of patients who arrived within 6 hours of LKW over a 4-month period was conducted. The NIHSS was completed by both the nurse (RN) and tele-stroke neurologist (physician) and was reviewed for components of the VAN screening tool to determine if patients were VAN positive or negative. The ability to identify LVO patients using the VAN screening tool was compared to NIHSS of ≥ 6.

Results:
Of the 111 patients that arrived within 6 hours of LKW, 40 (36%) were VAN positive, and 57 (51%) had NIHSS ≥ 6 based on RN assessment. Physician assessment identified 35 (32%) VAN positive, and 58 (52%) had NIHSS ≥ 6. A total of 18 patients were found to have LVO during the assessment period. Of these LVO patients, 15 had a documented RN assessment that identified 11 (73%) VAN positive and 13 (87%) had NIHSS ≥ 6. All 18 had physician assessments, with 17 (94%) VAN positive and 18 (100%) with NIHSS ≥ 6. NIHSS ≥ 6 had greater sensitivity than VAN (87% and 100% vs 73% and 94%) based on both RN and physician assessments, respectively. Whereas VAN had greater specificity (63.3% and 74% versus 43% and 41%). Based on RN assessment, VAN had a 92.6% negative predictive value (NPV) and a 28% positive predictive value (PPV) (vs 23% for NIHSS ≥ 6). Based on physician assessment, VAN had a 98% NPV and a 49% PPV.

Discussion:
VAN is a useful assessment tool for identification of LVO. However, it is associated with greater accuracy when used by the physician, rather than the RN. To optimize LVO screening, the RN may require focused training to improve assessment skills for both VAN and NIHSS.
Abstract WP373: Assessment Of Traditional And Nontraditional Cardiovascular Risk Factors In Older Adults With And Without Metabolic Syndrome.
Authors: GAILLARD Trudy R , Miller Elaine T , Bakas Tamilyn
Published: October 2018

Background and Purpose:
Metabolic Syndrome (MetS) is a constellation of risk factors that increase risks for cardiovascular disease (CVD) and mortality. However, whether additional nontraditional risk factors are associated with MetS in older adults is debatable. Therefore, in the current study we examined nontraditional risks factors and the MetS and its components in older adults at high risk for CVD.

Methods:
We measured the nontraditional CVD risk factors and MetS and its components in 75 independent living older adults (65-80 years). Fasting glucose, hemoglobin A1c, insulin, and systolic and diastolic blood pressure were measured. Insulin sensitivity was calculated using homeostasis model assessment (HOMA-IR) and body mass index (BMI). We measured nontraditional risk factors, lipids and lipoproteins and inflammatory markers, as well as MetS and its components in each participant.

Results:
The mean age of our group was 71.9±5.0 years and BMI 26.7±4.9 kg/m
2
. We found 24% of our participants had MetS compared to 76% without MetS. There were no differences in age or blood pressure among those with and without MetS. We found statistically significance differences in traditional MetS components; fasting glucose (105.1±14.1 vs. 93.1±10.0mg/dl, p=0.002); triglycerides (155.1±57.6 vs. 91.9±48.2mg/dl, p=0.0003); HDL-C (41±11.7 vs. 64.9±14.9mg/dl, p=0.001); and BMI (31.4±5.3 vs. 26.7±4.9kg/m
2
, p=0.002). Significant differences existed in HOMA-IR (5.3±3.5 vs. 2.1±2.1%, p=0.001) and Apo A1 (119.9±23.1 vs. 160±27.4mg/dl, p=0.0007) but not for Apo B, Apo CIII, Apo E, C-reactive protein, or IL-6.

Conclusions:
Our pilot data clearly demonstrates metabolic differences in older adults with and without MetS. Our study confirms that risk factors for CVD are higher in older adults with MetS. However, nontraditional risk factors were not different among our participants. Therefore, the MetS continues to be a valid measure of CVD risks in older adults.
Abstract WP375: Knowledge of Warning Signs and Risk Factors Among Rural Population in Central Pennsylvania
Authors: Beckett Lisa , Groody Angela , Sadighi Alireza , Zand Ramin
Published: October 2018

Background:
Good knowledge of stroke warning signs and risk factors reduces prehospital delay and increases stroke survival. The goal of this study was to identify public stroke knowledge in a rural area in central Pennsylvania.

Materials and Methods:
In a cross-sectional study, people attending the 2016 Sullivan County Health Fair in Pennsylvania were interviewed to assess their knowledge of stroke risk factors and warning signs. A structured closed-ended multiple choice questionnaire was administered. Respondents answered questions about stroke warning signs and risk factors. Further questions asked about their reaction to acute stroke and the source of their stroke knowledge.

Results:
Out of 163 respondents, 85% of respondents selected ≥3 (out of 4) correct stroke warning signs, and 72% of respondents selected ≥3 (out of 5) correct stroke risk factors. About one-third of respondents selected neck pain or chest pain as a stroke warning sign. Identification of ≥ 1 (out of 3) wrong stroke warning signs were significantly lower among the respondents of post graduate level education in comparison with other literacy groups (23%, P<0.001). 96% of respondents chose “call 911 immediately” when responding to an acute stroke. A relative with a history of stroke was the most cited source of information. Multivariate analysis found that higher level of education increases odds of knowledge of ≥3 correct stroke risk factors. Knowing anyone with stroke was related to familiarity with life-threatening nature of the stroke (r=0.205, P<0.01).

Conclusion:
Respondents’ knowledge of warning signs for stroke was favorable. About 85% of respondents recognized at least three stroke warning signs with no significant age and literacy effect. Our results provide some evidence that the subjects most at risk of stroke are the group with the least knowledge of stroke risk factors. Therefore elderly population should be one the main target groups in stroke awareness programs.
Abstract WP378: Sleep Duration and Aortic Stiffness: the Multi-Ethnic Study of Atherosclerosis
Authors: Logan Jeongok , Lobo Jennifer M , Sohn Min-Woong , Kang Hyojung , Redline Susan , Punjabi Naresh M , Lin Gen-Min , Lima Joao A , Kwon Younghoon
Published: October 2018

Large-arterial stiffness is recognized as a subclinical marker of cardiovascular disease (CVD). Self-reported short and long habitual sleep duration has been implicated in increased arterial stiffness. However, studies that use objective assessments of sleep duration while accounting for confounding effects of sleep apnea are scarce. We examined the association between habitual sleep duration, as assessed by actigraphy, and magnetic resonance imaging (MRI)- based aortic stiffness, controlling for other CV risk factors including sleep apnea.

Method:
We included participants in the Multi-Ethnic Study of Atherosclerosis who had undergone MRI assessment of aortic distensibility and a sleep study. Sleep duration was assessed by wrist actigraphy for 7-days and aortic stiffness by aortic pulse wave velocity (aPWV), ascending aorta distensibility (AAD), and descending aorta distensibility (DAD) using MRI. Multiple linear regressions were used to evaluate the association between sleep duration (defined as: short:< 6 hours, normal: 6-8 hours, and long: > 8 hours) and aPWV, AAD, or DAD, adjusting for demographic, life style factors, common cardiovascular risk, and apnea-hypopnea index.

Results:
The sample consisted of 908 participants (Mean age 68.4±9.1 years, 55.3% women). There was a significant linear trend of increased aPWV across short, normal, and long sleep durations (8.4 ± 3.6 vs. 8.7 ± 4.2 vs. 9.9 ± 4.9, respectively, p=0.008). In multivariable model, participants with short sleep duration (n=252), had average 0.87 m/s (95% CI: -1.47, -.27) lower PWV and 0.23 mmHg
-1
(95% CI: .01, .45) higher DAD, compared with those with normal sleep duration (n=552). No significant difference in PWV or DAD was found between those with normal and long sleep duration. No associations were noted between sleep duration and AAD. Sleep duration had no significant interactions with age, gender or race.

Conclusion:
This study shows that short sleep duration, as assessed by actigraphy, is significantly associated with low aortic stiffness measured by MRI in a large community-based cohort. Future studies on the association between sleep duration and aortic stiffness are warranted to confirm these findings and elucidate potential underlying mechanisms.
Abstract WP380: Oregon Region Standard Stroke Neurological Assessment Utilizing AACN Synergy Model
Authors: Swearingen Natalie , Cox Kailey , Clark Diane
Published: October 2018

Background:
Best practice guidelines recommend using standardized valid assessment tools to trend neurological assessment of acute stroke patients. The Oregon region and nationally recognized accrediting bodies for stroke certifications have identified Glasgow Coma Scale (GCS) as inadequate for quickly trending a patient’s neuro status after IV alteplase (t-PA) and/or thrombectomy.

Purpose:
Develop a stroke neurological check that is quick to perform, more complete than a GCS, and provides a snapshot of patient status including original neuro symptoms.

Methods:
Stroke program coordinator nurses and clinical experts from the Oregon region collaborated, conducted literature review, and developed a recommendation for a new standard stroke neuro check. The new stroke neuro check or SNAP (Stroke Neuro Assessment by Providence) entails 4 major parts: Level of consciousness as defined by NIH Stroke Scale (NIHSS) 1a, 1b, 1c or GCS; Pupil reactivity to light; movement of extremities as defined by NIHSS 5a, 5b, 6a, 6b, and finally trending patient’s original stroke symptoms. Throughout development of this standard stroke neuro check, we applied the Synergy Model combining stroke patient characteristics, health care environment, and nurse competencies. As a professional model of care, we incorporated the AACN Synergy Model to standardize RN education tools for implementation throughout ED, critical care, and stroke units.

Results:
One certified comprehensive stroke center and three certified primary stroke centers implemented SNAP in various stages throughout their hospitals within a 9 month time period. Multiple education methods were used including, 1:1 staff education, laminated tip sheets, computer sticker reminders, safety huddles, staff meetings, stroke classes, SNAP pen lights, continuous quality improvement feedback aimed at improving nurse competency, and electronic medical record enhancements to harmonize environment of documentation with RN workflow.

Conclusion:
The definition of a stroke neuro check continues to be controversial. Successful Oregon region development and implementation of SNAP through AACN Synergy Model, meets regulatory and practice requirements as a standard stroke neuro check.
Abstract WP383: Neuropsychological Outcomes Following Pediatric Cerebral Sinovenous Thrombosis
Authors: Maxwell Emily C , Hassara Kathleen , Bernard Timothy J , Boada Richard
Published: October 2018

Introduction:
Few research studies have investigated neuropsychological domains beyond IQ in pediatric cerebral sinovenous thrombosis (CSVT). Additionally, prior studies have contained small sample sizes making generalization of results difficult. This study investigates a broad set of neuropsychological domains in pediatric CSVT and identifies predictors of poor outcomes.

Hypothesis:
Children with CSVT were predicted to have worse cognitive outcomes compared to the normative sample. Earlier age at CSVT and the presence of acute symptoms associated with CNS dysfunction (e.g., altered mental status, aphasia, ataxia, seizure, and hemiparesis) were also hypothesized to predict worse long-term outcomes.

Methods:
20 children (mean age = 15.6 years) who suffered a CSVT during childhood (range = 3.6 to 18.0 years) participated in this study. Children completed a comprehensive neuropsychological battery and parents completed several standardized behavioral questionnaires. Testing was completed at least 6 months post-CSVT. Data were analyzed using one-sample
t
-tests and ANOVA.

Results:
Children with CSVT had significantly greater problems on measures of mood, behavior, visual-motor integration, and processing speed compared to the normative sample (all
p
-values < 0.05). There were also trends for children with CSVT to have poorer performance on measures of confrontation naming (
p
= 0.051), sentence repetition (
p
= 0.064), and metacognition (
p
= 0.057). Age at the time of CSVT was a significant predictor, such that older age at CSVT was associated with poorer single word reading and poorer visual-motor integration, but higher adaptive functioning. In these preliminary findings, acute symptoms associated with CNS dysfunction did not significantly predict outcomes.

Conclusions:
To our knowledge, these findings represent the largest study to date investigating a broad set of neuropsychological domains following pediatric CSVT. This population demonstrated weaknesses in visual-motor integration and processing speed compared to the normative sample. Additionally, these children exhibited more mood and behavior symptoms, supporting the need for careful psychological follow-up in this vulnerable population.
Abstract WP384: Special Considerations for Endovascular Therapy in Children With Cardiac Disease
Authors: Lee Sarah , Dodd Robert , Chen Sharon , Ryan Kathleen , Bonneville Fabrice , Cheuret Emmanuel , Nasr Nathalie , Olivot Jean M , Amlie-Lefond Catherine M
Published: October 2018

Introduction:
Children with congenital heart disease are at increased risk for stroke due to large vessel occlusion. Mechanical thrombectomy is standard of care for treatment of large vessel occlusion in adults; however, appropriate protocols for children, particularly those with complex cardiovascular anatomy and hemodynamics, are not well established.

Methods:
We report 3 cases of children with known cardiac disease who presented with acute stroke symptoms and underwent thrombectomy between May-July 2017. Baseline characteristics, stroke presentation, endovascular treatment, complications and outcomes of each case were reviewed, along with the cardiac anatomy and cardiopulmonary status of each patient.

Results:
Case details are reported in Table 1. All three patients had an M1 occlusion and minimal to absent early infarct signs on initial CT. Thrombolysis in Cerebral Infarction (TICI) score of 2C or 3 was achieved and small final stroke burden sustained in all cases (Figure 1). Cardiopulmonary status caused significant complications leading to death for one patient, and necessitated alterations in standard neuroprotective measures for another.

Conclusion:
Children with genetic or congenital cardiac disease represent a significant subset of pediatric stroke patients amenable to endovascular therapy. Our cases highlight complications which may arise when treating these anatomically complex and often hemodynamically tenuous patients. These children represent an important subgroup for whom specific endovascular pathways should be developed.
Abstract WP385: Altered Adaptive Immune Response Correlates With Brain Injury in Extracorporeal Membrane Oxygenation Treated Pediatric Patients
Authors: Ortega Sterling B , Pandiyan Poornima , Windsor Jana , Torres Vanessa O , Selvaraj Uma M , Kong Xiangmei , Raman Lakshmi , Stowe Ann M
Published: October 2018

Extracorporeal Membrane Oxygenation (ECMO) is a life-saving procedure that provides short-term cardiac and respiratory support to people whose heart and lungs are dysfunctional. Growing use of ECMO has expanded the indications beyond acute severe respiratory and cardiac failure to include extracorporeal cardiopulmonary resuscitation and as a bridge for lung transplantation. Usage of ECMO within the pediatric population has seen a number of complications including an acute induction of systemic inflammatory response syndrome (SIRS) and long-term developmental neurological deficits, with an increasing number of children exhibiting neurological morbidities. We hypothesized that ECMO may potentiate the induction of a central nervous system (CNS)-targeting adaptive immune response which may lead to neurological injury. Using a single center prospective observational study, we sampled 20 pediatric ECMO patients and 5 aged-match disease control patients. Peripheral blood mononuclear cells were isolated using the Ficoll-Paque method and relative analysis revealed an increase in helper T-cells that correlated with ECMO treatment alone, while NK-T cells were found to be increased in the presence of CNS injury. Interestingly, we did see a decrease in activated peripheral T-helper cells (CD4+CD161+), and cytotoxic T cells (CD8+CD161+), which were preceded by an increase in activated macrophages (CD14
+
CD11b
+
) in ECMO treated patients. Only activated peripheral CD8 T-cells were found to associate with CNS injury. Using the CFSE recall response assay, we tested for CNS specificity by culturing cells with myelin basic protein (MBP), proteolipid lipoprotein (PLP), myelin oligodendrocyte glycoprotein (MOG), NMDA receptor GluN2A, and microtubule associated protein (MAP2) for 7 days and determined a response by measuring CFSE dilution and CD25 expression using flow cytometry. We observed an increased in myelin-targeting B-cells, myelin- and neuronal-targeting CD8 T-cells and no difference in autoreactive CD4 T-cells. In summary, ECMO induces a robust peripheral CNS-targeting adaptive immune response that may predispose a patient to long-term neurological injury.
Abstract WP39: The Effect of July Admission on Inpatient Morbidity, Mortality, and Discharge Disposition After Endovascular Coiling in Subarachnoid Hemorrhage
Authors: De la Garza Ramos Rafael , Haranhalli Neil , Kobets Andrew J , Nakhla Jonathan P , Brook Allan , Yassari Reza , Flamm Eugene S , Altschul David J
Published: October 2018

Introduction:
The “July effect” refers to the perceived notion that new hospital staff (students, residents, fellows, etc.) first starting training in July may contribute to an increased rate of adverse events during patient care. The purpose of this study is to investigate the effect of July admission on short-term outcome after endovascular coiling of patients with subarachnoid hemorrhage (SAH) due to ruptured aneurysms.

Methods:
Data from the National Inpatient Sample (2012 - 2014) was gathered. Adult patients with primary discharge diagnosis of SAH who underwent endovascular therapy at a teaching hospital were identified. Patients with intracranial injury, arteriovenous malformation, and associated craniotomy were excluded. Admissions during July were compared to other months, as well as based on admission quarter: AQ1 (Jul - Sep), AQ2 (Oct - Dec), AQ3, (Jan - Mar), and AQ4 (Apr - Jun). Outcome measures included inpatient morbidity (death, iatrogenic stroke, or myocardial infarction), inpatient mortality, and non-routine discharges.

Results:
There were 8,515 patients with diagnosis of SAH who underwent endovascular coiling between 2012 and 2014 from the NIS database. Among these, 665 (7.8%) were admitted in July and 7,850 (92.2%) in other months. Overall, there were no differences in any of the examined outcomes, including morbidity (15.0% vs. 17.3%, p=0.513), mortality (10.5% vs. 11.8%, p=0.665), or non-routine discharge (57.1% vs. 59.7%, p=0.567) for patients admitted in July versus other months, respectively. Based on AQ, 24.5% of patients were admitted in AQ1, 26.0% in AQ2, 23.8% in AQ3, and 25.7% in AQ4. Similar to July vs. other month admissions, there were no significant differences in outcomes based on AQ.

Conclusion:
Based on the findings of this national investigation, patients with SAH due to ruptured aneurysms who undergo endovascular therapy during the beginning of the academic year in July may not have worse short-term outcome compared to admissions during other months.
Abstract WP390: Mechanical Thrombectomy and Intravenous Tissue Plasminogen Activator in Pediatric Arterial Ischemic Stroke: Lessons From a Case Series
Authors: Tidwell Tracy J , Bhattarai Paras M
Published: October 2018

Introduction:
Stroke is one of the 10 most common causes of death in children. With no randomized studies in children on safety in efficacy, use of tissue plasminogen activator(tPA) and mechanical thrombectomy is limited. Consensus based guidelines are available for the use of thrombolysis in children with arterial ischemic stroke(AIS).

Objective:
a.) Retrospectively review and analyze patients who had either IV tPA or mechanical thrombectomy or both b.) compare with similar studies

Methodology:
Study was conducted at Le Bonheur Children’s Hospital in Memphis TN. Data collected as part of International Pediatric Stroke Study, starting from January 2016 until March 2017(15 months) were reviewed retrospectively. Literature review was conducted to compare results. All patients included had at least one follow up after 3 months after the treatment.

Results:
Out of 38 patients diagnosed to have AIS, four of them (10 %) underwent either tPA or mechanical thrombectomy or both. Age ranged from 14 to 17 years. Pediatric NIH stroke scale on arrival ranged from 6-9. Dose of tPA as well as inclusion and exclusion criteria was based on Thrombolysis in Pediatric Stroke(TIPS) study. All of them had MRI or CT angiogram detection of stroke and arterial occlusion before the procedure. Duration of symptoms to the initiation of one the hyper-acute treatment was 3.5 to 4.5 hours in all except one who underwent thrombectomy for basilar artery thrombosis. One got only tPA thrombolysis, two had both tPA followed by mechanical thrombectomy and the fourth, had basilar artery thrombosis, underwent only thrombectomy with suction as the patient arrived beyond 4.5 hours’ window. No complications were noticed. On follow up after 3 months, 3 out four had full recovery.The fourth patient still had expressive aphasia and cognitive deficits who on MRI head with contrast was found to have persistent enhancement in the cortical area suggestive of vasculitis.

Conclusion:
In conclusion, 10% of total AIS patients, underwent IV thrombolysis or mechanical thrombectomy and had no complication; similar data was reported in prior studies. However,randomized controlled trials would be necessary to substantiate the validity or reliability of the use of IV tPA or mechanical thrombectomy in pediatric AIS.
Abstract WP391: Post-Stroke Diastolic Blood Pressure and Risk of Recurrent Vascular Events
Authors: Park Jongho , Ovbiagele Bruce
Published: October 2018

Background:
Recent clinical trials and expert consensus guidelines have typically focused on the issue of systolic blood pressure (SBP) targets for reducing vascular risk. However, little is known about the relationship of diastolic BP (DBP) level with vascular outcomes after a stroke.

Methods:
We analyzed a multicenter trial dataset involving 3680 recent (<4 months) noncardioembolic stroke patients followed for 2 years. Subjects were categorized per mean DBP level (mm Hg) during follow-up: low-normal (<70), normal (70 to <80), high-normal (80 89), and high (>=90). Pulse pressure (PP) was prespecified by three categories of <60; 60 to <70; and >=70 mm Hg. Independent associations of mean DBP level with stroke, coronary heart disease, or vascular death as major vascular events (MVEs), and ischemic stroke were assessed.

Results:
MVEs occurred in 20.7% of the low-normal, 15.1% of the normal, 16.9% of the high-normal, and 19.2% of the high DBP groups; while stroke occurred in 9.9%, 6.8%, 8.5%, and 10.8%, respectively. Compared with the normal DBP group, risk of MVEs was higher in the low-normal DBP group (adjusted hazard ratio [AHR], 1.33; 95% CI, 1.04–1.71). Among those with SBP 120 to <140 mmHg, risk of MVEs (AHR, 1.89; 95% CI, 1.13-3.15), and stroke (AHR, 2.87; 95% CI, 1.48-5.53) was higher in subjects with PP >=70 (mean DBP, 62.4 ± 3.8) than those with the lowest PP (mean DBP, 78.0 ± 5.9); while among those with SBP <120 mm Hg, PP 60 to <70 (mean DBP, 52.7 ± 2.5) was associated with increased risk of stroke (AHR, 5.85; 95% CI, 1.25-27.5).

Conclusion:
DBP levels in the low-normal (<70 mm Hg) range, particularly accompanied by an increased PP of >60, confer increased future risk of MVEs and stroke, among patients with a recent noncardioembolic stroke.