bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP317: Reducing Hospital-acquired Pneumonia Rate in Stroke Patients
Authors: Diebolt Elizabeth , Andrie Rebecca , Bleck Thomas , Drakes Susie , Gayatin Pamela , Henseler Mary , Hernandez Christian , Goodman Diana , Livesay Sarah , Segreti John , Daily Deval , Jivana Anisa , Conners James
Published: March 2022

Objective:
To reduce the hospital-acquired pneumonia rate in stroke patients.

Background:
The hospital-acquired pneumonia rate for stroke patients at our institution was 6.2% in 2014. This is the 39th percentile for the Joint Commission Comprehensive Stroke Centers in the University HealthSystem Consortium. Our goal was to achieve top decile performance by reducing our hospital-acquired pneumonia rate for stroke patients to 3.0%.

Methods:
A multidisciplinary team was assembled with representation from administration, coding, nursing, resident physicians, and attending physicians from stroke, neurocritical care and infectious disease. The team analyzed benchmarking data and decided to use chart review to validate the data. The team decided to use the CDC’s definition and clinical criteria for hospital-acquired pneumonia. Further chart review was performed to find information on swallow evaluations, incentive spirometer use, oral care, and head of bed elevation. A coding manager reviewed the documentation and the coding decision for each patient. After results were presented, the team decided on a course of action.

Results:
Review of stroke patients with hospital-acquired pneumonia showed 44% of the patients coded with pneumonia did not meet the clinical definition on physician review. When reviewed by a coding manager, all coding was found to be correct based on the documentation in the chart. To solve this documentation problem, attending physicians discharging stroke patients were informed of these results about unclear pneumonia documentation and were asked to clarify documentation if the diagnosis was not appropriate. After this change, the hospital acquired pneumonia rate in stroke patients fell from 6.2% prior to the changes from April 2014 to March 2015 to 1.9% after the changes were implemented from April to June 2015.

Conclusion:
Our facility was able to reduce the rate of hospital-acquired pneumonia in stroke patients from 6.2% to 1.2% through a multidisciplinary approach to achieve more accurate documentation and coding. The widespread over-documentation showed it is clinically difficult to make a diagnosis of pneumonia in this population. Therefore, the rate of hospital-acquired pneumonia is not a valid measure of quality of care.
Abstract WP324: Integrated Systems Enhance Equitable and High-Quality Stroke Prevention Clinic Care
Authors: Gocan Sophia , Bourgoin Aline , Hall Ruth , Khan Ferhana , Zhou Limei , Stotts Grant
Published: March 2022

Stroke prevention clinics were established in Ontario to provide comprehensive, equitable, evidence-based care for patients at high risk of stroke. However, depending on where patients present with their stroke symptoms there are differences in access to diagnostic services. Patients presenting to a primary care office or small hospital, have limited or no access to diagnostic services compared to those presenting to large academic hospitals. To overcome this inequitable access to stroke expertise and diagnostics, we developed a standard referral protocol, a centralized approach to triage and dedicated diagnostic imaging services in regional stroke prevention clinics. The objective of our research was to evaluate the degree to which these system supports have resulted in comprehensive stroke prevention best practice care.

Retrospective data analysis was completed using the FY 2011/12 Ontario Stroke Audit of Secondary Stroke Prevention Clinics database. We examined differences in secondary stroke prevention best practices across the five stroke prevention clinics and if there were differences in practice by referral source (Emergency vs. Primary Care).

A total of 1853 patients were seen at the five Champlain stroke prevention clinics in 2011/12. The majority of referrals were initiated from Emergency Departments 58.7%, followed by primary care 29.2%, specialists 9.2% and inpatient units 2.8%. Overall, high rates of neuroimaging (97.6%), and vascular imaging (97.6 %) were achieved with little variation across stroke prevention clinics. There was no variation in imaging rates by referral source. The stroke prevention clinics facilitated neuroimaging and vascular imaging for almost 30% of patients, as they did not have these tests completed at the site of initial presentation.

Implementing a centralized stroke prevention clinic referral and triage system has enabled equitable access to essential diagnostic testing in the Champlain region. Rapid diagnostic imaging plays a vital role of in identifying stroke etiology, and influences patient prioritization, treatments and management in the stroke prevention clinic setting. Future research should include evaluation of patient outcomes relative to the timing of diagnostic testing.
Abstract WP337: Publication Bias and Low Power Contribute to the Efficacy Decline of Neuroprotective Drugs From Experimental Stroke Studies to Phase Iii Clinical Trials
Authors: Schmidt Antje , Wellmann Jürgen , Bruckmann Nils-Martin , Strecker Jan-Kolja , Diederich Kai , Minnerup Jens
Published: March 2022

Background:
In spite of several successful experimental studies, neuroprotective drugs have always failed in large clinical trials. We aimed to determine the efficacy decline of neuroprotectants from animal studies to early phase and phase III clinical trials. Moreover, we aimed to identify study characteristics of experimental studies and clinical trials, which contribute to the efficacy decline of neuroprotective drugs.

Methods:
We identified all phase III clinical trials and corresponding experimental studies and early clinical trials of neuroprotective drugs for ischemic stroke. The overall efficacy of neuroprotective drugs in experimental studies, early phase and phase III clinical trials was determined by means of a meta-analysis. We performed power analyses and estimated the publication bias in experimental studies and clinical trials. Stratified meta-analyses will be performed to identify study characteristics (e.g. randomization, blinded outcome assessment, time to treatment) which influence the results of experimental studies and clinical trials.

Results:
We identified 47 phase III trials, 190 corresponding experimental studies and 66 corresponding early clinical trials. Seventy-seven percent of experimental studies and 39,4% of early clinical trials reported a positive result in at least one treatment arm. By contrast, there was only one positive phase III trial, which was followed by a larger negative trial. Funnel plot asymmetry revealed a major publication bias in experimental studies. The mean power of experimental studies was 47,3%.

Conclusion:
Our study illustrates the efficacy decline from experimental studies to phase III clinical trials. Publication bias and low power inflate the efficacy of neuroprotective drugs in experimental stroke studies.
Abstract WP345: ‘Palliative Care Encounter’ for Stroke Patients in US
Authors: Singh Tarvinder , Creutzfeldt Claire , Tirschwell David
Published: March 2022

Background:
Patients with stroke have a high risk of death, physical and cognitive impairments and therefore have a high degree of palliative care (PC) needs. The goal of this study is to explore the prevalence of and associations with PC consultation in stroke patients across the country.

Methods:
Using the 2010-2012 Nationwide Inpatient Sample database, we reviewed all patients discharged with stroke (based on ICD-9 codes) from 2010-2012. Strokes were sub-classified as ischemic, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). We collected information on demographics, outcome and presence of a “Palliative Care encounter” as defined by the ICD-9 code V66.7.

Results:
Overall, there were 395,411 stroke patients with a mean age of 70.11 (SD 16), 52% were female and 69% white. The majority of patients had ischemic strokes (86%) followed by ICH (10%) and SAH (4%). A PC encounter was found in 24,642 patients (6.2%) and was more common in patients with older age, hemorrhagic stroke types, those discharged from larger hospitals and in more recent years (all p<0.05). Higher rate of PC encounters was found for women (OR 1.23, 95% CI 1.19-1.26). Blacks and Hawaiian/Pacific Islanders had less use of PC than whites (all p <0.05). About 9% of patients died in hospital, of which 38% received a PC encounter.

Conclusions:
PC encounters are becoming more common for stroke patients, especially in larger hospitals and are strongly associated with hospital death (i.e. more common used in more severe strokes). The unequal distribution across age, gender, stroke type and race suggests a need for more standardized methods to identify patient’s need for PC consultation such as validated PC consultation triggers.
Abstract WP346: HIAT2 Predicts Poor Functional Outcome, Palliative Care Involvement, and In-hospital Mortality in tPA Treated and Untreated Ischemic Stroke Patients
Authors: Kaur Manmeet , Boehme Amelia K , Albright Karen C , Lyerly Micheal , Sisson April , Arora Kanika , Khawaja Ayaz M , Hays Shapshak Angela , Gropen Toby
Published: March 2022

Introduction:
The HIAT2 (Houston Intra Arterial Therapy-2) score has been used to predict poor functional outcome in acute ischemic stroke (AIS) patients undergoing endovascular therapy (ET). Little is known about HIAT2’s ability to predict other outcomes in non-ET samples.

Aim:
To test the ability of HIAT2 to predict poor functional outcome (mRS 4-6), in-hospital mortality, and inpatient palliative care (PC) consult in (1) ET, (2) IV tPA, and (3) untreated patients.

Methods:
A retrospective review of consecutive AIS patients presenting to our comprehensive stroke center (CSC) from March 2014 to April 2015. Demographic and clinical data were collected. HIAT2 was calculated as follows: age (≤59=0, 60-79=2, ≥80=4), glucose (<150=0, ≥150=1), NIHSS (≤10=0, 11-20=1, ≥21=2), ASPECTS Score (8-10=0, ≤7=3). We used AUC to measure the ability of the HIAT2 score to predict our three outcomes of interest.

Results:
Among the 776 AIS patients admitted to our CSC, 6.6% received acute ET, 14.6% received IV tPA, and 79.8% received neither. For
ET
patients HIAT2 had an AUC of 0.592 for mRS 4-6, AUC 0.569 for PC, and AUC 0.656 for death. For
tPA
patients HIAT2 had an AUC of 0.686 for mRS 4-6, AUC 0.798 for PC, and AUC 0.825 for death. For
untreated
patients HIAT2 had an AUC of 0.629 for mRS 4-6, AUC 0.649 for PC, and AUC 0.641 for death. In the tPA treated sample, a HIAT2 score ≥4 had a sensitivity and specificity of 0.436 and 0.819 in predicting mRS 4-6, sensitivity and specificity of 0.667 and 0.782 for PC, and sensitivity and specificity of 0.733 and 0.806 for death.

Discussion:
Our results suggest that the variables used to create the HIAT2 score are useful in predicting poor outcomes in untreated, tPA treated, and ET patients. Despite its ability to predict poor outcome in these samples, treatment should not be withheld from patients that otherwise qualify.
Abstract WP352: Imaging Parameters Alone Predict Early Recurrent Cerebrovascular Endpoints in Patients with Transient Ischemic Attack and Minor Stroke
Authors: Yaghi Shadi , Rostanski Sara K , Boehme Amelia K , Martin-Schild Sheryl , Samai Alyana , Silver Brian , Blum Christina A , Siket Matthew , Jayaraman Mahesh , Khan Muhib , Furie Karen L , Elkind Mitchell S , Marshall Randolph S , Willey Joshua Z
Published: March 2022

Background:
There remains lack of consensus on who among minor stroke or transient ischemic attack (MS-TIA) patients constitutes a high-risk group that may be targeted by clinical trials to improve early recurrence risk. We aimed to determine predictors of early recurrent cerebrovascular endpoints (RCVE) among patients with MS-TIA.

Methods:
We retrospectively analyzed data from consecutive patients who presented to the emergency room of Columbia University between Jan 1
st
2010 - Dec 31
st
2014, with MS-TIA (NIHSS 0-3) diagnosed by a neurologist and within 12 hours from onset. The outcome (adjudicated by 3 stroke neurologists) was RCVE (neurological deterioration defined as worsening deficits not attributed to fever or other medical condition or recurrent ischemic stroke or TIA within hospitalization). Our primary predictor was large vessel disease (LVD) stroke subtype. Covariates included demographics, stroke risk factors, symptoms, and imaging parameters. We confirmed our findings in an independent cohort of consecutive MS-TIA patients (NIHSS 0-3) evaluated at Tulane University during the same time period.

Results:
The cohort at Columbia University Medical Center included 505 patients; mean length of hospital stay (LOS) 3.2 days, 31 had RCVE (6.1%). The Tulane cohort consisted of 753 patients (mean LOS 4.5 days), 40 had RCVE (5.3%); RCVE predictors on univariate and multivariate analyses in both cohorts were LVD subtype and to a lesser extent positive neuroimaging (Tables 1 and 2). There was an increase in percentage of patients with RCVE with both predictors combined as compared to separate use. When neither predictor was present, the rate of RCVE was very low (Figure). RCVE was associated with poor discharge outcome (mRS≥2).

Conclusion:
In patients with MS-TIA, LVD stroke subtype and perhaps positive neuroimaging predict RCVE in two independent cohorts.RCVE was associated with poor functional outcome. Prospective studies are needed to confirm our findings.
Abstract WP358: APOE Polymorphisms Influence Longitudinal Lipid Trends Preceding Primary Intracerebral Hemorrhage
Authors: Phuah Chia-Ling , Raffeld Miriam R , Ayres Alison M , Biffi Alessandro , Gurol M. Edip , Viswanathan Anand , Greenberg Steven M , Rosand Jonathan , Anderson Christopher D
Published: March 2022

Introduction:
Primary intracerebral hemorrhage (ICH) remains one of the most severe forms of acute cerebrovascular disease. APOE ε2 and ε4 are risk factors for primary ICH, and also involved in regulation of circulating lipid levels. Hypercholesterolemia has been associated with reduced ICH risk. However, the biological mechanisms mediating the roles of APOE and serum lipids on ICH risk remain unclear. Given the pleiotropic relationship between APOE, ICH, and serum lipid levels, we sought to determine the influence of APOE genotype on temporal serum lipid trends before and after ICH.

Methods:
We performed a single-center retrospective longitudinal cohort analysis using subjects with known APOE genotype drawn from an ongoing cohort study of primary ICH. Serum lipid measurements for total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), and high-density lipoprotein (HDL) collected within 2 years preceding and following index ICH were extracted from electronic medical records (EMR). Piecewise linear mixed-effects random-coefficent models were used to compare APOE allele-specific effects on changes in serum lipid trends in ICH.

Results:
124 ICH cases were analyzed. APOE ε4 carriers had significantly greater rates of decline in serum TC and LDL levels within 6 months prior to ICH (TC: -7.30 mg/dL/month, p=0.0035; LDL: -8.44 mg/dL/month, p=0.0001) compared to non-carriers (TC: -3.79 mg/dL/month, p=0.17; LDL: -2.39 mg/dL/month, p=0.55). In contrast, TC and LDL trends for APOE ε2 carriers were not significantly altered within the same time period. APOE genotype had no associations with serum HDL or TG trends.

Conclusions:
APOE allele status is a strong predictor of subacute serum TC and LDL changes preceding ICH. Our results have implications for ongoing efforts in dissecting the role of dyslipidemia in cerebrovascular disease risk. While further studies are needed, our observation that APOE ε4 influences serum lipid trends preceding ICH provides additional insight towards lipid-dependent and lipid-independent APOE-genotype specific effects on stroke risk and suggests that characterization of the metabolic role of APOE is needed to improve understanding of APOE biology in cerebrovascular disease.
Abstract WP363: DVT Prophylaxis in Intracerebral Hemorrhage Patients in a Large Health System: a 5 Year Analysis
Authors: Zurasky John F , Stuchiner Tamela , Baraban Elizabeth
Published: March 2022

Background:
The percentage of deep vein thrombosis (DVT) prophylaxis in intracerebral hemorrhage (ICH) patients remains low despite American Stroke Association guidelines. As part of a multi-hospital system wide quality initiative, we sought to determine the compliance of DVT prophylaxis in our population of ICH patients retrospectively and resulting rate of DVT/ pulmonary embolism (PE) to establish a baseline for comparison in future years to further standardization and quality of care.

Methods:
Data from 25 facilities in the Providence Health System Stroke Registry were analyzed from 2010 to 2014. Patients included were those who had a principal diagnosis of ICH and documentation was present for whether DVT or PE had occurred. Patients who were placed on comfort measures at any time during hospitalization were excluded. Descriptive analysis was conducted to assess use of chemical versus mechanical venous thromboembolism (VTE) prophylaxis and whether or not patients had a documented DVT or PE.

Results:
There were 1,581 ICH patients included in the analysis. Mean age at hospitalization was 67.0 (±15.5) and 55.4% were male. Of those that received VTE prophylaxis, 72 patients (4.4%) received chemical prophylaxis, including low-dose unfractionated heparin (LDUH), low-molecular-weight heparin (LMWH), factor Xa inhibitor or warfarin. Mechanical VTE prophylaxis including intermittent pneumatic compression (IPC), graduated compression stockings, or venous foot pumps were administered to 1,427 patients (87.6%). 127 patients (7.8%) had no documentation of VTE prophylaxis. Among those who received either chemical or mechanical VTE prophylaxis, 35 patients (2.5%) had documentation of a DVT or PE during the hospital encounter. Of those patients who had a DVT or PE, one patient received both LDUH and IPC. The remaining 34 patients who had a DVT or PE (97.1%) received only mechanical VTE prophylaxis.

Conclusion:
Pharmacologic DVT prophylaxis rates were very low. The rate of DVT/PE was in line with other published rates. Pharmocologic DVT prophylaxis was superior to mechanical means alone. A large study documenting the safety and efficacy of pharmacologic DVT prophylaxis in these patients is needed.
Abstract WP368: Atrial Fibrillation in Patients With Intracerebral Hemorrhage - Proportion of Patients With Indications for Anticoagulation
Authors: Tirschwell David L , Sheth Kevin N , Leira Enrique C , Kamel Hooman , Greenberg Steven M , Rosand Jonathan
Published: March 2022

Introduction:
Atrial fibrillation (AFib) patients who have recently experienced intracerebral hemorrhage (ICH) may otherwise have an indication for preventive anticoagulation. The use of anticoagulation in these patients, despite strong evidence of reduction of embolic risk, is controversial and lacks high quality supportive evidence.

Methods:
Using data from the National Inpatient Sample from 2010-2012, we estimated the proportion of ICH patients that survive their hospitalization, have AFib, and also an indication for anticoagulation. ICD-9 codes were used to identify ICH patients and relevant co-morbidities. Descriptive statistics and multivariate logistic regression were used.

Results:
39,395 patients had a primary ICD-9 diagnosis of ICH. The mean age was 69 years (SD 15), 49% were women, 18.5% had AFib and 25% died in hospital. Of AFib ICH patients that survived hospitalization (13% of all ICHs), 73% had a CHADS2 score >= 2. In multivariate analysis AFib ICH patients were significantly older, more likely male, Caucasian, had worse outcomes and higher prevalence of all CHADS2 risk factors compared to non-AFib ICHs (all p <= 0.001). AFib ICH patients discharged home with CHADS2 >= 2 comprised 2.2% of all ICH patients, and an additional 7.3% were discharged to rehabilitation or skilled nursing facilities.

Conclusions:
AFib ICH patients with appropriate indications for long term preventive anticoagulation represent up to 9.5% of all ICH patients. More research is needed to accurately estimate the rates of subsequent ischemic and hemorrhagic events, stratified by antithrombotic medication use. Such rates can then be used to estimate sample size for a randomized trial comparing the effectiveness of antiplatelet and anticoagulant medications.
Abstract WP382: Feasibility Testing of mHealth for brainHealth: a Mobile Intervention to Support Secondary Stroke Prevention
Authors: White Carole L , Ihegword Byron , Patterson Michele , Motz Deb , Williamson Richard , Caron Jean-Louis , Birnbaum Lee A
Published: March 2022

Background:
Mobile technologies provide the possibility to interact with stroke survivors in supporting risk factor self-management with much greater frequency, in real-time, and over the long-term, in their home environment where daily management of health takes place. The objective was to test the feasibility of a mobile intervention to support risk factor management.

Methods:
mHealth for brainHealth was developed with a user-centered approach, undertaken in 3 sequential phases: 1) focus groups with stroke survivors to understand their perception on risk factor management; 2) survey about blood pressure (BP) control and use of technology; and 3) a pilot study to examine feasibility of a mobile intervention that combines home BP monitoring (HBPM), a mobile application (app) to transfer and display BP readings, and text-messaging support around BP and other risk factors, reported here. Stroke survivors were provided with Bluetooth-enabled HBPM and a Smartphone with the BP app, along with training on BP measurement and the intervention. They were instructed to measure their BP daily, which was then transferred to a server, triggering automated messages and alerts related to BP. Participants also selected two other areas of risk and were sent regular educational text messages. Participants provided feedback at study end.

Results:
Fifteen stroke survivors with hypertension, 48 to 81 years of age, 70% male, 73% Hispanic, on average 4 months poststroke, tested the intervention for 6 weeks. All reported the system was important for their health and mostly fit into their daily schedule. Some reported difficulty with the technology, which prompted changes to the training program. Participants were 80% adherent to the BP measurement schedule. They reported the BP messages were very informative and improved understanding of their BP readings. While educational messages were important, participants felt messages should be more motivating. Participants reported improved knowledge about risk factor control.

Conclusions:
Results of this pilot study demonstrate feasibility of the mobile intervention and also show areas for improvement. Participant feedback is being incorporated into the redesign, to be tested in a randomized controlled trial.
Abstract WP385: The Stroke Transitions Education and Prevention Clinic: a Comprehensive Approach to Post-stroke Care
Authors: Sharrief Anjail , Okpala Munachi N , Vu Kim Yen Thi , Savitz Sean I
Published: March 2022

Background:
Aging of the population is expected to lead to increased numbers of stroke survivors in the US. However, there are no organized outpatient systems of care dedicated to risk factor and complication management of stroke survivors in the U.S.

Purpose:
We sought to establish a stroke prevention clinic wherein a comprehensive approach to the management of discharged stroke patients would be implemented by a physician and nurse practitioner (NP).

Methods:
We obtained input from multiple stake-holders including physicians and mid-level providers, hospital and clinic administrators, social work, and stroke survivors and caregivers. Our conceptual framework for effective post-stroke care incorporated stakeholder input, evidence-based guidelines, and critical appraisals of literature related to risk factor modification and stroke recovery. Together with the stroke NP, we developed protocols for risk factor and complication assessment and management, created educational materials at appropriate literacy levels, and trained clinic staff in administration of Patient Health Questionnaire 9 (PHQ-9, depression), Epworth sleepiness scale (ESS, sleep apnea), and Morisky medication adherence scale (MedAd).

Results:
We began the pilot phase of the Stroke Transitions Education and Prevention (STEP) Clinic on June 16, 2014 and established the clinic registry in October 2014. From June 16 , 2014 to July 15, 2015, 222 patients were evaluated in the clinic by the stroke NP or MD. Median time to follow-up was 41 days (IQR 32, 56). The population was 45.5% female, 59% racial/ethnic minority, and median age was 62 (SD 13.8). Among patients with ischemic (70.7%) and hemorrhagic (21.2%) stroke, initial clinic blood pressure was controlled for 67.5% and 72.3%, respectively. PHQ-9, ESS, and MedAd were complete for 92.7%, 89%, and 86.5% of participants, respectively.

Conclusions:
The STEP clinic was developed and implemented to facilitate provision of comprehensive care to stroke survivors. Post-stroke clinics may aid in improving risk factor control and quality of life after stroke. Patient co-management with NPs can increase institutional capacity for providing post-stroke care.
Abstract WP386: Swallowing Assessment of Nurses and Speech-Therapists
Authors: Stolzenburg Joanna , Ott Anja , Bulut Cem , Ringleb Peter A
Published: March 2022

Background:
A relevant number of stroke patients have swallowing disabilities; assessment of swallowing ability is an important procedure on a stroke unit to reduce complications. There is still doubt whether or not a trained nurse has a similar efficacy in the assessment of swallowing difficulties as does a specialized speech therapist (ST).

Methods:
Our ST has trained any stroke unit nurse (SN) in assessment of swallowing function. A test using first thickened flavored water (custard consistency) and 5 ml water is done.

For a pilot study, during 6 weeks all stroke unit patients with cerebral ischemia were included. Patients with TIA, non-stroke diagnoses or altered consciousness (score 2-3 for item 1a of the NIHSS) were excluded. Swallowing function was evaluated independently by the patient’s SN and latest on the next working day by the ST. A 5 step scale was used, measuring from no food, to 2 different texture-modified diets, to normal food.

Cohen’s kappa statistic was calculated to evaluate congruence of the assessments. Univariate statistics were done to analyze difference between cohorts with equivalent and different grading.

Results:
Overall 90 patients were included (53% male, 93% ischemic stroke, mean age 71 years). In 72 (80%) of the SN and ST scored identical (10% no food allowed, 11% special food preparation, 79% no problem). In 11 (12%) SN were more careful than the ST, and in 7 (8%) the SN assessed less swallowing-problems than the ST. Cohens’s kappa was 0.6067. In four of those patients the ST found relevant swallowing problems, which could have led to feeding abstention (2 patients) or special food preparation (2 patients). Comparing those 18 patients with differences in the assessments and those 72 without, presence of dysarthria was the only different parameter and was more present in the patients with varying rating (Mann Whitney U, p=0.0019)

Conclusion:

In this unselected cohort of ischemic stroke patients, swallowing problems were detected in 32%, when using the ST’s assessment as gold standard. Inter-rater agreement with a trained SN was good. In a small percentage (8%) nurses had overseen swallowing problems and in 4% this was relevant. Presence of dysarthria was the only factor, which was different between equal and unequal graded patients.
Abstract WP392: Ventriculitis Related to Venticular Catheteres Eradicated With the Creation of Strict Guidelines for Insertion to Maintenance to Removal
Authors: Freund Jennifer , Simonowicz Patricia , Rinaldi Maria
Published: March 2022

Background and Purpose:
External ventricular catheters (EVDs) are an essential modality used to treat and manage critically ill neurosurgical, neurology, and trauma patients. Although EVD’s benefits are well understood their use has been tempered by complications associated with the device. Chief among the complications are infections related to the catheter. In the fall 2013 it became evident that our Intensive Care Unit (NICU) had an outbreak of ventriculitis related to EVDs. Review of cerebral spinal fluid studies from 2012- 2013 revealed an average 6.4 ventricular catheter related infections per 1000 EVD days. A multidisciplinary team was created to create guidelines from insertion, to maintenance, accessing, and removal. The purpose of the team was to institute guidelines to reduce our rate of ventricular related infections.

Methods:
A multidisciplinary team was formed that included an intensivist, neurosurgery physician, neurosurgery physician assistant, neurocritical care nurse practitioners, neurocritical care nurses, operating room nurses, an infection control nurse, and a pharmacist. The group review current policies and procedures. Only one policy was found that was created in 1992 and had never been revised. The work group reviewed current literature and policies and procedures from other institutions. Our initial policy was extensively revised, and two new policies were created. The new policies were approved by all members of the work group and presented and accepted by the medical executive committee. The new policies were instituted between September 2013 and April 2014. Educational in-services were provided to all members of the healthcare team responsible for insertion, maintenance, and removal of EVDs.

Results:
After implementing and educating staff on the new policies we saw a significant reduction in infection rates related to EVDs. In 2014 we had 2.05 ventricular related infections per 1000 EVD days, and in the first 6 months of 2015 we currently have 0 ventricular related infections per 1000 EVD days.

Conclusion
There was a significant reduction of catheter related ventriculitis after strict adherence to guidelines created by a multidisciplinary team.
Abstract WP396: The Need for Speed: Streamlining the Stroke Alert Process
Authors: Brackman Jennifer M , Beichler Kristen
Published: March 2022

Background and Issues:
Restoring perfusion to the brain is key to the patient’s recovery and has been at the forefront of stroke treatment and research for the past decade. AHA/ASA has continually challenged acute stroke programs to reduce their IV t-PA door-to-needle (DTN) times. Developing an interdisciplinary team-based approach has helped our stroke program meet, and at times, exceed the door-to-needle time goal for IV t-PA.

Purpose:
In response to the AHA and The Joint Commission’s goal, the team re-designed the stroke alert process from the time the patient arrives at the hospital in order to give IV t-PA more expeditiously.

Methods:
Critical improvements of the current process were identified such as taking the stable patient straight to the CT scanner from the squad, transferring the patient to a weigh-capable bed from the CT scanner, pre-mixing IV t-PA if the CT is normal, patient eligibility and staff education. An addition of a clinical pharmacist to the stroke alert team has also helped to drive down our DTN times. EMS teams and Aultman ED staff were educated regarding the AHA/ASA goal and the importance of rapid patient triage, prompt initiation of the stroke alert process, coordination of diagnostic evaluation and the administration of t-PA.

Results:
In 2013, the average door to needle time was 79.2 minutes. In 2014, the average door to needle time was 68.7 mins. In January of 2015, our team initiated the “Straight to CT” protocol change and the current DTN is 48.3 minutes. Aultman was a recipient of the Target: Stroke Honor Roll award in 2015 and we have maintained our Gold Plus status for Get With The Guidelines performance for 6 consecutive years.

Conclusions:
Developing a team approach and identifying opportunities for improvement for care are essential in the success of a stroke program. Effective and efficient stroke care remains Aultman Hospital Stroke Center’s goal and we strive daily for excellence in stroke care.
Abstract WP399: Effectiveness of Acute Stroke Team in a Regional Primary Health Care Hospital
Authors: Jones Brett , Patel Ronak
Published: March 2022

Introduction:
Stroke is the second leading cause of death in Australia. In 2012, the total financial costs of stroke in Australia were estimated to be $5 billion. Costs are estimated to be higher for regional or rural hospitals, especially those without acute stroke services. Studies have shown significant benefit of an acute stroke team in improving thrombolysis rates, reducing door-to-CT, door-to-needle and in- hospital mortality. But this model is largely adapted by metropolitan tertiary health care hospitals. The benefit of implementing acute stroke service in a primary care hospital is not known.

Aim:
We undertook an internal audit to evaluate the effectiveness of acute stroke team in improving thrombolysis rates, door-to-CT, door-to-needle, length of stay (LOS) and mortality in a regional primary health care hospital.

Methods:
Data from 6 months pre and post commencement of acute stroke team and stroke unit was collected retrospectively. A literature review was undertaken with search terms “stroke”, “acute stroke team”, “stroke unit” and “mortality”.

Results:
We identified 152 and 160 patients pre and post commencement of services. Of 312 all strokes, 152 and 160 patients were admitted pre and post stroke unit respectively. There was a 3 fold increase in the number of stroke calls and thrombolysis rates increased from 7.6% to 12.9%. A reduction of 44mins and 20mins was seen in door-to-CT and door-to-needle times respectively. The mean LOS reduced 50% from 8 to 4 days while in-hospital mortality dropped from 12.5% to 6.25%. Failure rate of admission swallow screen assessment improved 10-fold from 51% to 5%, although assessment data was missing in 33 pre-stroke unit patients. Cost-benefit analysis showed a $600 saving per patient.

Conclusions:
Our study highlights the advantage of an acute stroke team in improving thrombolysis rates, door-to-CT and door-to-needle times, and swallow screen assessment. It reduces LOS and in-hospital mortality and results in an annual saving of $96,000. We plan to expand our service after hours and perform a larger prospective study to confirm our findings with the long-term aim of providing service to a wider catchment area.
Abstract WP411: Anatomical Venous Variants and Physiological Adaptive Changes in Children With Cerebral Sinovenous Thrombosis
Authors: Kouzmitcheva Elizabeth , Andrade Andrea , Armstrong Derek , Muthusami Prakash , Moharir Mahendranath
Published: March 2022

Objective:
Cerebral venous vessels a have unique morphology. No information is available regarding the presence of anomalous venous structure and related consequences in children. We aim to describe the frequency of anatomical variants (persistent fetal structures), and physiological changes (collateralization), in children with CSVT. We hypothesize that these variations impact in the re-distribution of venous drainage in the presence of stressors such as anemia or dehydration.

Methods:
We retrospectively reviewed children (1 month - 18 years), with CSVT over 5 years (Jan 2008 - Dec 2013). We excluded children with arterial ischemic stroke, trauma, compressive intracranial lesions and systemic venous hypertension. We reviewed for symptoms at presentation, risk factors, sinus involved, thrombus location, parenchymal lesions, antithrombotic therapy, outcome using the Paediatric Stroke Outcome Measure (PSOM) and recanalization rate at last follow-up. MRV/CTV reports were evaluated for anatomical variants and physiological changes in the venous systems.

Results:
Thirty-four children were identified. 17 boys (50%), with mean age at CSVT of 13.5 years (0.2 -17.6 years). 11 had anatomical variations (32%) vs. 23 (68%) with typical anatomy. These included 6 (54%) children with abnormal sinus morphology (hypoplasia/absence of a major dural sinus), 3 (27%) children with persistent fetal structures and 6 (54%) with prominent collateralization. Most of the cases had > 1 anatomical variant together. Signs of increased intracranial pressure were seen more frequently in children with anatomical variants 7(63%) than in those without variants 7(30%), although not statistically significant. 5 children (45%) with anatomical variations had brain parenchymal involvement vs. 5 (22%) with normal anatomy. Mean recanalization rate was the same between the two groups: 10(90%) at mean follow-up of 5.5mo (3 - 9mo) in the variant vs. 22(96%) at 4.2mo (1.5 - 9mo) in the normal anatomy group.

Conclusion:
The presence of anatomical variants in the cerebral venous structures may be associated with a more severe initial presentation in children with CSVT. Variant venous anatomy may be less efficient in compensating for the obstruction to venous outflow due to thrombosis.
Abstract WP419: Predictors of Post-Discharge Physical Activity in Patients With Mild Ischemic Stroke
Authors: Kawajiri Hiroyuki , Mishina Hiromi , Asano Sho , Kono Yuji , Hayashi Hironori , Niwa Jun-ichi , Izumi Masayuki , Doyu Manabu , Kimura Shinya , Yamada Sumio
Published: March 2022

Introduction:
Low daily physical activity (PA) is a risk for stroke recurrence. However, the predictors of PA have not been well investigated in mild ischemic stroke (MIS). This study aimed to identify the predictors of PA after discharge in MIS.

Methods:
We performed a single center registry, prospective observational study. Acute MIS with modified Rankin Scale (mRS) of 0-2 were consecutively enrolled. Baseline examination during hospitalization consisted of age, gender, National Institute of Health Stroke Scale, mRS, Mini-Mental State Examination, stroke subtype, cerebral white matter lesions, body mass index, blood pressure, ankle brachial index, blood laboratory tests, metabolic syndrome, handgrip strength, knee extensor isometric muscle strength (KEIMS), 10m maximum walking time, decisional balance for exercise, self-efficacy for walking (SE-W), social support for exercise (SSE), anxiety and depression. PA was measured at 6-months post-discharge by electronic accelerometer. The mean daily step counts and time of moderate to vigorous-intensity (≥3 Metabolic Equivalents) PA (MVPA) were used as an index of PA (total counts over 7 days/7). For multiple logistic regression analysis, step counts and MVPA were categorized into two groups divided by each median value. The baseline variables which had P <0.10 in the univariate analyses of step counts or MVPA were entered into the multiple logistic regression analyses with adjustments of age and gender.

Results:
163 MIS (115 male, 69.5±10.1 years) were successfully followed for 6-months post-discharge. After multivariate analyses, KEIMS (increment of 0.1 Nm/kg: OR=0.829, 95%CI=0.717-0.959, p=0.011), SE-W (increment of 1 point: OR=0.917, 95%CI=0.850-0.989, p=0.025) and SSE (increment of 1 point: OR=0.882, 95%CI=0.789-0.987, p=0.029) for step counts, and SE-W (increment of 1 point: OR=0.930, 95%CI=0.867-0.999, p=0.047) for MVPA were selected as independent predictors.

Conclusions:
The findings of the present study suggest that an appropriate target group of low-PA MIS can be identified by simple measurements/questionnaires during hospitalization.
Abstract WP43: Advanced White Matter Disease is Associated With Increased Blood-Brain Barrier Permeability and Early Diffuse Microstructural Changes in Patients With Acute Ischemic Stroke
Authors: Etherton Mark , Wu Ona , Lauer Arne , Boulouis Gregoire , Cloonan Lisa , Cohen Abigail S , Copen William , Telles Cougo-Pinto Pedro , Rost Natalia S
Published: March 2022

Background:
In acute ischemic stroke (AIS), cerebral tissue damage and clinical outcomes are linked to pre-existing microvascular dysfunction, manifesting as white matter hyperintensity (WMH). Elevated blood-brain barrier permeability (BBB-P) has been implicated in advanced WMH. We tested the microstructural integrity of BBB as measured by dynamic susceptibility contrast (DSC) MRI K
2
coefficient values in AIS patients with advanced WMH.

Methods:
Twenty patients enrolled in a prospective acute MRI study underwent diffusion tensor (DTI) and DSC MRI on admission for AIS. BBB-P estimates were derived from DSC MRI using the K
2
coefficients. Fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) maps were calculated. Mean K
2
, MD, AD, RD and FA values were measured in regions of WMH and normally appearing white matter (NAWM) in the hemisphere contralateral to AIS and compared (two-tailed Student t-Test). WMH volume (WMHv) was assessed on acute FLAIR using a validated semi-automated volumetric protocol. Linear regression was performed to evaluate significant predictors of K
2
, MD, AD, RD, and FA. Correlation analysis was performed (Pearson product-moment).

Results:
Mean age of subjects was 66 (±10) years, 30% were women, median WMHv 3.5cm
3
[IQR 1.6-7.4]. K
2
values differed significantly between WMH and NAWM (0.32 x10
-3
vs. 1.1 x10
-3
, p<0.03), as did the diffusivity metrics for WMH and NAWM (FA: 0.25
vs
0.38; MD: 1.3 x10
-3
vs
0.84 x10
-3
; AD: 1.6 x10
-3
vs
1.2 x10
-3
; RD: 1.14 x10
-3
vs
0.66 x10
-3
; all p<0.0001). K
2
and RD

values were correlated within WMH (R=-0.45, P=0.046) but not in NAWM (R=0.06, P=0.81). Multivariate analysis found systolic BP (SBP) and lnWMHv to be significant predictors of MD (P=0.0009), AD (P=0.002), and RD (P=0.002) in NAWM.

Discussion:
BBB-P and diffusivity values in patients with AIS and advanced leukoaraiosis differed significantly between WMH and NAWM in the hemisphere contralateral to acute infarct. Association between the RD and K
2
coefficients in WMH suggests the role of BBB-P in pathophysiology of WMH and the loss of microstructural white matter integrity associated with it. Further, the influence of SBP and lnWMHv on NAWM diffusivity values suggests ongoing risk for developing future WMH.
Abstract WP434: Decreased Manual Dexterity is Associated With Low Fractional Anisotropy in the Fornix of Healthy Middle-aged Persons at Risk for Vascular Disease
Authors: Hannawi Yousef , Yanek Lisa R , Kral Brian G , Vaidya Dhananjay , Becker Lewis C , Becker Diane M , Nyquist Paul A
Published: March 2022

Introduction:
Decreased fornix fractional anisotropy (FA) on diffusion tensor imaging (DTI) in normal ageing has been associated with impaired problem solving, working memory and motor tasking, but its role in multi-dimensional cognitive-motor tasks in apparently healthy people has not been studied. Also, the extent of its association with vascular disruption remains unclear. White matter lesions of presumed ischemic origin on MRI are associated with decrements in Grooved Pegboard test (GPBT) in young asymptomatic family members of probands with premature coronary artery disease (CAD).

Hypothesis:
We hypothesized that decrements in GPBT in this population, is associated with decreased FA in relevant brain regions.

Methods:
The GPBT was averaged for both hands. DTI was acquired on a Phillips 3T scanner (slice thickness 2.2 mm, field of view 212X212 mm and b-value 700 mm
2
/s). The brain was segmented into 181 regions with Large Deformation Diffeomorphic Metric Mapping using the Eve atlas. Pearson correlations of regional FA values and log-transformed GPBT scores were performed and Multivariable GEE linear regression (adjusted for family relatedness) was done for regions meeting the Bonferroni threshold of 0.00028 (0.05/181).

Results:
Subjects with DTI and GPBT data were included (N=115, mean age 49± 11 years; mean education 14 ± 3 years; 49% male; 41% African American). GPBT score was normal (106±15) seconds. Higher GPBT (worse performance) was negatively correlated with FA in regions of the left (L) and right (R) frontal and temporal lobes and L&R corpus callosum not meeting Bonferroni threshold (p=0.0046, 0.036, 0.026, 0.0015, 0.02, 0.0007), whereas the L&R fornix and L external capsule (EC) did meet threshold (L fornix R=-0.37, p=5.9E-05; R fornix R=-0.47, p=1.3E-07, L EC R=-0.35, p=8.1E-05). After adjusting for age, sex, race, and education every 25% lower FA in the R fornix was associated with 12% decrement in GBPT (R fornix p=0.05, L fornix and EC p=0.19).

Conclusions:
Decreased fornix FA is associated with worse manual dexterity in a healthy middle-aged population with a family history of early onset CAD, at risk for future cerebrovascular disease. This suggests injury of the fornix fibers may represent early ischemic injury in this population.
Abstract WP436: Comparing Risk of Stroke and Death in Treated and Untreated Patients With Unruptured Brain Arteriovenous Malformations (BAVM)
Authors: Kim Helen , Nelson Jeffrey , McCulloch Charles E , Lawton Michael T , Mohr Jay P , Stapf Christian , Al-Shahi Salman Rustam ,   Multicenter AVM Rsch Study (MARS) Investigators
Published: March 2022

Background:
Management of unruptured BAVM remains controversial despite recent clinical trial results demonstrating a 3-fold increased risk of stroke and death in treated versus medically managed patients. We compared outcomes between treated and untreated patients with unruptured BAVMs using observational data from the Multicenter AVM Research Study (MARS).

Methods:
MARS consists of 3 unruptured cohorts: UCSF (n=416), Columbia (n=223), and the Scottish Audit of Intracranial Vascular Malformations (n=70). We used a propensity score adjusted analysis with Cox proportional hazards regression of time to adverse event (stroke or death) from date of diagnosis or treatment, censoring at last follow-up (up to 5 years) to compare the group receiving any interventional treatment of embolization, gamma knife, or surgical resection (‘treated’) to the group receiving medical management (‘untreated’). The propensity score for treatment was computed using logistic regression with predictors of age, age2, sex, Caucasian race, cohort, Spetzler-Martin score, and reason for presentation.

Results:
There were 709 unruptured BAVM patients (565 treated/144 untreated). A total of 81 adverse events (68 strokes/13 deaths) occurred during 1632 patient-years of follow-up for an annual rate of 5.0% (95% CI: 4.0%-6.2%) overall, 5.6% (4.4%-7.2%) in the treated group, and 4.6% (2.0%-5.4%) in the untreated group. There was a trend for increased risk of adverse events in the treated group (HR=1.5, 95% CI:0.8-2.7, p=0.180). In stratified analysis, subjects in the highest propensity quintile (i.e., those most expected to receive treatment) seemed to have lower rates of adverse events in the treated versus untreated group (HR=0.4, 95% CI:0.1-1.5, p=0.178). An analysis using all patients except those in the highest quintile suggested outcomes were worse in the treated group (HR=1.81, 95% CI:0.96-3.4, p=0.065).

Conclusion:
Our results suggest an increased risk of adverse events in unruptured BAVMs that are treated. However, taking into account propensity for treatment revealed a possible subgroup that may benefit from treatment. Larger sample sizes are needed to identify risk factors and develop risk stratification models for unruptured BAVMs.