bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP32: 3mmx20 Trevo Retriever vs. Penumbra 3 Max Distal Occlusion Acute Stroke Thrombectomy
Authors: Haussen Diogo C , Eby Brendan , Al-Bayati Alhamza , Grossberg Jonathan A , Rodrigues Gabriel M , Frankel Michael , Nogueira Raul G
Published: January 2019

Introduction:
The optimal approach for distal intracranial occlusions in thrombectomy for acute ischemic stroke is unclear. We aim to compare our experience with 3mmx20 Trevo Retriever against the Penumbra 3max in small vessels.

Methods:
Retrospective review of a prospective thrombectomy databank for consecutive cases of use of 3mmx20 Trevo Retriever or Penumbra 3max for middle cerebral artery (MCA) mid or distal M2, M3, anterior cerebral artery (ACA A1, A2, A3) or posterior cerebral artery (PCA P1, P2) from Jan 2014-July 2018.

Results:
Of 1071 patients treated within the study period, 136 patients/144 different arteries underwent treatment with small devices (3mmTrevo n=92 vs 3Max n=52). There was no difference in the distal occlusion presentation: isolated distal occlusion, emboli to new or same distal territory, or multiple occlusions (p=0.11). The distribution of occlusions site was comparable (p=0.37). Demographics were comparable including age, gender, hypertension, atrial fibrillation, systolic blood pressure, last-normal to puncture. The use of intravenous alteplase was similar (p=0.47) as well as the use of balloon guide catheter (p=1.00). The approached vessel pre-clot diameter was comparable between the 3mmTrevo and 3Max groups (1.6±0.2mm vs 1.4±0.3;p=0.66), respectively. The frequency of superior vs inferior vs middle MCA division was similar (p=0.42) amongst arms. A trend for higher first-pass mTICI2b-3 reperfusion was noted in the 3mmTrevo (62% vs 44%;p=0.05) vs 3Max group. Rates of first-pass full reperfusion was comparable (42% vs 34%;p=0.38). Adjuvant therapy was used less frequently in the 3mm Trevo group (15% vs 31%;p=0.03) for comparable final mTICI3 rates (p=0.22). The number of passes (1.3±0.5 vs 1.3±0.6; p=0.9) and the frequency of arterial spasm (any spasm; p=1.00) were comparable between groups. 90-day rates of good outcomes (35/76 vs 21/43; p=0.84) were comparable amongst arms. Subarachnoid hemorrhage (p=0.37) and parenchymal hematomas (p=0.21) in the territory of approached vessel was similar.

Conclusions:
The 3mm Trevo may lead to enhanced rates of successful reperfusion as compared to 3Max thromboaspiration. Further studies are warranted.
Abstract TP320: Endothelial Nitric Oxide Synthase (eNOS) Inhibition Abolishes the Exercise-Induced Improvement in Neurovascular and Neurobehavioral Stroke Outcomes
Authors: Hafez Sherif S , Khan Mohamed B , Hess David C
Published: January 2019

Background:
Clinically, it was shown that increased physical activity reduces the risk of stroke and severity of outcomes. However, the underlying mechanism is not clear. Endothelial nitric oxide synthase (eNOS) activation was shown to improve vascular function and reduce the risk of cardiovascular diseases. However, the role of eNOS in mediating short term exercise-induced improvement in stroke outcome was not previously studied. Accordingly, we tested the
hypothesis
that acute short term pre-stroke exercise improves stroke outcomes through increased eNOS activity, and that eNOS inhibition abolishes these beneficial effects.

Methods:
Male Wistar rats (300 g) were subjected to high intensity interval training (HIIT) through treadmill running sessions for four days (25 minutes/day), break for 2 days and then one acute bout for 30 minutes. Exercised animals were subjected to thromboembolic stroke at 1h, 6h, 24h or 72h after the last exercise session. At 24h after stroke, sedentary and exercised rats were tested for neurological outcomes, infarct size and cerebral edema. Western Blotting was used to measure the expression of active eNOS (p-S1177-eNOS) in brain and cerebral vessels. Additional control and 1h exercise groups were treated with eNOS inhibitor (L-NIO (L-N
5
-1-Iminoethyl ornithine)) right after stroke (I.P. injection, dose: 20 mg/Kg).

Results:
Acute exercise significantly reduced infarct size, edema and improved functional outcomes, and increased the expression of peNOS in the brain and cerebral vessels. eNOS inhibition significantly increased the infarct size, edema and worsened the neurobehavioral outcomes in exercised animals compared to non-treated group (table).

Conclusion:
Short term acute pre-stroke exercise significantly reduced neurovascular injury and improved neurobehavioral and functional outcomes after stroke, and eNOS inhibition abolished these beneficial effects.
Abstract TP327: Plant Long-Chain Isoprenoid Alcohols (Polyprenols) Protect Against Cerebral Ischemia and Reperfusion Injury in a Mouse Model of Stroke
Authors: Shvedova Maria , Soultanov Vagif , Trusov Vladimir , Atochin Dmitriy N
Published: January 2019

Introduction:
Plant long-chain isoprenoid alcohols (polyprenols) are biologically active molecules affecting the isoprenoid pathway. Polyprenols have broad therapeutic actions including for infections and inflammatory, hepatic and neurological conditions. The aim of this study was to evaluate the protective effects of pharmaceutical-grade polyprenols on experimental stroke in a mouse middle cerebral artery occlusion (MCAO) followed by reperfusion model.

Methods:
Pharmaceutical-grade polyprenol substance, Ropren®, is isolated from green verdure of (
Picea abies (L) Karst)
. Adult (12-14 weeks old) C57BL/6 male mice were anesthetized (1.5% of isoflurane in 30% of O
2
and 70% of N
2
O) and body temperature was maintained (36.5-37.0°C) during 30-min filament-mediated MCAO and 48 h of reperfusion. Cerebral laser-Doppler flowmetry was utilized during MCAO to test whether regional cerebral blood flow (CBF) differences correlated with stroke outcome. Before and 24 h after MCAO, the experimental group was treated with Ropren® intraperitoneal injections (12 mg/kg) diluted in 100 μl sunflower oil. The control group was treated with 100 μl oil only at the same time points. Mice were euthanized 48 h after MCAO and infarct volumes were calculated (indirect method) after TTC staining.

Results:
Experimental stroke revealed a decrease in the cerebral infarct volume in the Ropren-treated group (51±16 mm
3
, Mean±SD) in comparison with the control group (67±13) (n=10/group, p < 0.05, two-tailed t-test). Neurological deficit measured by a 4-point scale was improved in Ropren-treated mice (1.2 points) compared with control mice (1.8) (n=10/group, p=0.05). We did not find a significant difference both between intra-ischemic CBF and CBF during reperfusion between groups (15th minute of reperfusion: 62±24% in Ropren-treated mice; 77±35% in control mice (n=10/group, NS)). This suggests Ropren® renders its neuroprotective effects by mechanisms independent of CBF.

Conclusion:
This study shows the protective effects of pharmaceutical-grade polyprenols (Ropren®) during cerebral ischemia-reperfusion injury in the mouse MCAO model. Further research is required to understand the mechanisms of Ropren-mediated neuroprotection in this ischemic stroke model.
Abstract TP333: Motor Recovery After Transient Middle Cerebral Artery Occlusion May be Impacted by the Disruption of Nucleus Basalis-Cortical Cholinergic Pathways
Authors: Betz Dene M , Becker April M , Irani Anaiza S , Plautz Erik J , Goldberg Mark P
Published: January 2019

Stroke survivors often have chronic motor deficits that significantly impact their quality of life. The most common vessel affected by ischemic events is the middle cerebral artery. These strokes commonly affect the basal ganglia and internal capsule in humans and in rodent models of stroke. Our lab studies the neurotransmitter acetylcholine for its potential to drive cortical plasticity that may support recovery after cortical spinal tract damage. Cholinergic cells in the nucleus basalis (NB), a major cholinergic nucleus with axonal projections throughout the cortex, can drive the beneficial motor map reorganization induced by vagus nerve stimulation after stroke in rats (Kilgard et al., 2016). Our lab has previously shown that selective injury to NB cholinergic cells reduces motor recovery (Becker et al., Soc. for Neuroscience abstract. 800.09, 2014.). In the current experiments, we mapped NB projection pathways in transgenic mice expressing fluorescent proteins in cholinergic neurons. We crossed mice expressing Cre driven by the choline acetyltransferase (ChAT) promoter with mice expressing channelrhodopsin and EYFP with a floxed stop cassette driven by the CAG promoter, both obtained from Jackson Laboratories. Fixed brains were imaged with high-throughput fluorescence microscopy using either whole slide imaging of freezing microtome sections (Nanozoomer, Hamamatsu) or serial two-photon tomography of whole brains (TissueCyte 1000, TissueVision). Cholinergic cell bodies in the NB and their proximal processes were visually tracked from the basal forebrain to the cortex. We found that some NB cholinergic projections to motor cortex were immediately adjacent to the globus pallidus interna, which is typically injured by transient middle cerebral artery occlusion. If the axons of NB cholinergic cells that are projecting to the cortex are damaged by stroke, this pathway may impact the ability for stroke patients to recover motor functions by disrupting central motor learning pathways. Understanding neuromodulatory circuits involved in cortical plasticity and motor learning after stroke is essential for developing new therapeutic methods.
Abstract TP334: A Novel Murine Model of the Effects of Helicopter Emergency Medical Services Transportation on Ischemia and Thrombolysis
Authors: Dhanesha Nirav , Schnell Thomas , Rahmatalla Salam , DeShaw Jonathan , Parker Bradley , Chauhan Anil , Pieper Andrew , Leira Enrique
Published: January 2019

Background:
Helicopter emergent medical services (HEMS) transportation is critical for rapid transportation of patients for mechanical thrombectomy and rtPA-mediated reperfusion. However, the effect of the multiple unique physical factors present in HEMS on the outcomes of these procedures is not known. Experimental models of ischemia-reperfusion that replicate HEMS conditions are needed in order to address this issue before putative neuroprotective therapies during flight trials can be accurately evaluated.

Methods:
A novel experimental model of “drip & ship” during HEMS was developed using middle cerebral artery occlusion (MCAO) with autologous clot in mice and an Mi2 helicopter adapted for animal research. Since vibration is one of the most salient physical components in HEMS, we isolated this factor for mechanistic investigation. The vibratory signature during HEMS was recorded in-flight using accelerometers and then recapitulated in a six-degree-of-freedom man-rated Moog-FCS motion platform in the laboratory. We evaluated two approaches (simultaneous vs. sequential) to expose mice with MCAO to the three different settings (helicopter/simulator/ground) in order to find the most optimal methodologically.

Results:
A clot length of 30 mm and 90 min of rTPA initiation post MCAO achieved significant infarctions while minimizing periprocedural mortality. Two MCAOs were the maximum capable of achieving occlusion times <15 minutes apart. In order to maintain MCAO to rtPA times close to 90 minutes, a sequential exposure to the three settings (helicopter/simulator/ground) was established with 2 mice each. Randomly assigned exposure lasted for 1 h and occurred at the same time of the rtPA exposure. The three exposures were 2 hours apart to minimize the effect of atmospheric variations. The animal MRI facility was coordinated to acutely scan the animals after the three exposures.

Conclusion:
We have developed an animal model to study the effects of HEMS on rtPA/reperfusion. An ongoing experiment measuring infarction volume and clinical outcomes will determine the need to maintain an actual HEMS for future experiments, or whether a laboratory simulator will suffice.
Abstract TP336: Renal Denervation Reduces Cerebral Vasospasm After Subarachnoid Hemorrhage in Rats
Authors: Takemoto Yushin ,   Dept of Neurosurgery, Graduate Sch of Med Sciences, Kumamoto Univ, Hasegawa Yu , Hayashi Kenyu ,   Dept of Neurosurgery, Graduate Sch of Med Sciences, Kumamoto Univ, Mukasa Akitake , Kim-Mitsuyama Shokei
Published: January 2019

Background and Purpose:
Renal denervation (RD) was shown to have several organ protective effects via suppression of sympathetic nerve activation. As sympathetic nerve activation is involved in the pathogenesis of subarachnoid hemorrhage (SAH), RD can be a good candidate treatment to improve SAH prognosis. In this study, we hypothesized that RD reduced early brain injury and cerebral vasospasm (CVS) in SAH rats, both of which were major prognostic factors of SAH.

Methods:
Sprague-Dawley rats were divided into 3 groups: (1) Sham operation, (2) SAH+vehicle, and (3) SAH+RD. Bilateral RD were performed at 60 minutes after SAH induction. Twenty-four hours after SAH, we examined the effect of RD on the blood pressure (BP), neurologic score (NS), cerebral blood flow (CBF), brain water content (BWC),and diameter of basilar artery (BA). Then,the cytotoxic changesand sympathetic nerve activation were evaluatedby immunohistochemistry and western blot. Finally, serum angiotensin II which is one of the predictor of sympathetic nerve activation was measured by ELISA.

Results:
Although RD decreased elevated BP after SAH, the values of CBF were similar among the 3 groups. RD didn’t show significant improvement of NS and BWC, whereas it significantly prevented CVS. In BA, theexpression levels ofphosphorylated Extracellular Signal-regulated Kinase, Tumor Necrosis Factor-α, Matrix metalloproteinase-9, p22-phagocytic oxidase, and infiltration of macrophages were upregulated by SAH, but they were significantly reduced by RD. In the paraventricular nucleus (PVN) of hypothalamus which are one of the important nucleuses for sympathetic nerve activation, the increased expression of dopamine β-hydroxylase and reactive astrocytes by SAH were significantly suppressed by RD.Moreover,RD significantly decreased serum angiotensin II which were elevated after SAH.

Conclusions:
The present study demonstrated that RD reduced CVS after SAH and it may be came from suppression of sympathetic nerve activation.
Abstract TP337: Predictors of the Patient Activation Measure (PAM) Among Acute Stroke Survivors: An Analysis of the Michigan Stroke Transitions Trial (MISTT) Data
Authors: Fritz Michele C , Woodward Amanda T , Talge Nicole M , Reeves Mathew J
Published: January 2019

Introduction:
Stroke transitions-of-care are complex and effective self-management is required for success. Patient activation, measured by the Patient Activation Measure (PAM), is a self-management construct that measures knowledge, skill, and confidence to manage one’s own health. Scores from this 13-item instrument range from 0-100 with mean scores of 62 (SD=13). PAM has been validated among ill and healthy populations, however, little is known about what factors are associated with PAM among stroke survivors.

Methods:
This cross-sectional analysis of the Michigan Stroke Transitions Trial (MISTT) utilized interview data collected 7 days after stroke survivors returned home. Multivariable linear regression was used to identify independent associations between PAM scores and a range of patient factors including sociodemographic, perceived support, general health, and stroke-related characteristics. Age and education were forced into the model.

Results:
Of 265 participants, 180 (70%) completed the 7-day interview. Mean age was 66 years (range 27-90), 49% were female, 18% were non-white, 88% had ischemic stroke, and 53% were discharged to acute or sub-acute rehab. 64% also had a caregiver enrolled in the MISTT trial. The mean PAM score was 64.5 (SD=16). Perceived emotional support was positively associated with PAM score, while having a consented caregiver and higher self-reported post-stroke disability were negatively associated with PAM (Table).

Conclusions:
Perceived emotional support, caregiver involvement, and post-stroke disability were associated with patent activation. These may represent intervention targets for enhancing post-stroke transitions.
Abstract TP342: Effectiveness of Nursing Neuro-checks in Patients With Acute Stroke
Authors: De Leon-Benedetti Andres , Campo-Bustillo Iszet , Romano Jose G , Martinez-Clark Pedro , Koch Sebastian
Published: January 2019

Introduction:
In the certification of primary and comprehensive stroke centers The Joint Commission cites neuro assessments/reassessment (neuro-checks) as one of the most problematic standards. The role of neuro-checks (NC) is to readily detect neurological change, but it is surprising that the assessment has undergone relatively little scientific study. Their effectiveness in detecting worsening in acute ischemic stroke patients has not been well examined. The aim of this study is to establish the usefulness of neuro-checks to detect neurological deterioration.

Methods:
We performed a retrospective chart review of acute ischemic strokes treated with IV tPA in 2017 at a large Comprehensive Stroke Center. Demographics, baseline and 24-hour NIHSS score, vascular risk factors, vascular syndrome at presentation and neuro-check findings during the first 72 hours following admission were recorded. NC consist of an assessment of orientation, Glasgow Coma Scale (GCS), arm and leg strength and sensation. Neurological deterioration was defined as worsening in the clinical judgement of a vascular neurologist during daily patient visits. Frequency and reasons of neurological deterioration and detection rates by neuro-checks were collected.

Results:
107 patients were analyzed (52% male, age 69.7 ± 15.6 [mean+/-SD] years). Mean NIHSS score was 12 ± 7.3 on arrival and 7.8 ± 7.6 at 24 hours. An average of 63.3 ± 13.9 neuro-checks were performed per patient. Neurological deterioration was observed in 28 (26%) patients. Of these, 12 (42%) were detected by NC, 9 (32%) by nurses outside of the scheduled NC time and 7 (25%) remained undetected and were found during follow up physician visits. The most common components of the NC that helped detection were decreased motor strength and confusion. Most common reasons for failure to discover deterioration were gradual decline (3/7 [42%]) and transfer to floor (2/7 [28.5%]).

Conclusions:
While NC increase the chance of detecting neurological deterioration in patients with acute stroke a significant proportion of deteriorations are found outside scheduled assessments or remained undetected. This suggests that novel monitoring strategies are needed to readily identify worsening neurological status in acute stroke.
Abstract TP346: Out-of-Pocket Healthcare Expenditures Among Older Americans With Stroke: Data From the Medical Expenditure Panel Survey 2003-2014
Authors: Lekoubou Alain , Bishu Kinfe , Bruce Ovbiagele
Published: January 2019

Introduction:
Out of pocket healthcare (OOP) expenditures may undermine continuing efforts to equitably curb mortality among elderly stroke survivors. We sought to evaluate, at a national level out of pocket expenditures among old stroke survivors.

Methods:
the Medical Expenditure Panel Survey (MEPS) 2003-2014 was used to identify old participants (65 years and older) with stroke. Unadjusted mean OOP expenditures for stroke were compared between elderly with stroke and without stroke. Using a generalized linear model (GLM), we estimate the adjusted incremental OOP expenditure among elderly, incurred by stroke and selected chronic conditions. We accounted for the complex survey design in order to allow the generalization of OOP cost for US population.

Results:
In all, 2,297 older patients with stroke were identified (representing 2,092,859 of the civilian noninstitutionalized US population). Mean OOP expenditures among elderly stroke participants was $2,010 (95% CI: 1,839-2,181). The incremental cost of total OOP expenditures for stroke among elderly was $379 (95% CI 206-550, p <0.001). In comparison, among elderly, the adjusted incremental total OOP expenditure for stroke was higher than that of hypertension, diabetes, COPD and arthritis but lower than that of Parkinson disease, depression and heart diseases.

Conclusion:
OOP expenditures among elderly stroke survivors are high and may represent a burden to fully implement recent medical progress in stroke care.
Abstract TP349: Submitted and Accepted Abstracts by Sex at the International Stroke Conference: Analysis of Trends From 2014-2018
Authors: Fournier Lauren E , Zhu Liang , Perez-Pinzon Miguel A , Ovbiagele Bruce , McCullough Louise D , Sharrief Anjail Z
Published: January 2019

Introduction:
Males have higher numbers of publications than females across many medical specialties. Little is known about female involvement in stroke research, especially conference-related science.

Objective:
To evaluate sex differences among authors of abstracts at the International Stroke Conference (ISC).

Methods:
Data were obtained (2014-2018) for first authors of submitted and accepted ISC abstracts from the American Heart Association. Variables included sex, career classification, career level, institution country, abstract category and type. Data were analyzed by chi-square test, Fisher’s exact test, or logistic regression.

Results:
Authors submitted 8532 abstracts (36.9% female), and 6135 abstracts were accepted (36.5% female). There was no difference in submitted abstracts by sex and year (p=0.3), so years were combined. There was no sex difference in the proportion of accepted abstracts (female vs male: 71.7% vs 73.0%, p=0.2). Nurses with accepted abstracts were most likely female (93.2%), and physicians were least likely (27.4%). By career level, the highest proportion of females with accepted abstracts was students/trainees (40.7%), and by institution continent, the highest and lowest proportions were from South America (56.7%) and Asia (19.9%). Females presented 91.5% of abstracts in nursing, 56.3% in clinical rehabilitation and recovery (next highest), and 18.0% in acute endovascular (lowest). The odds of being a female author was 1.82 (95% CI 1.62-2.05) in rehabilitation and recovery and 1.18 (95% CI 1.01-1.39) in basic science as compared to acute care. There was no sex difference in abstract presentation type (p=0.3).

Conclusions:
Females are underrepresented among ISC abstract first authors, especially among physicians and for acute, in-hospital stroke research, fields in which males may be overrepresented. This suggests the need for further efforts to increase the participation of females in stroke research.
Abstract TP351: Comorbid Psychiatric Disease is Associated With Lower Revascularization Rates for Stroke Due to Carotid Stenosis
Authors: Bongiorno Diana M , Daumit Gail L , Gottesman Rebecca F , Faigle Roland
Published: January 2019

Background:
Carotid endarterectomy (CEA) or stenting (CAS) decrease future stroke risk in patients with stroke due to carotid stenosis. Mental illness is pervasive in the U.S., and patients with psychiatric comorbidities experience inequities in treatment for a range of conditions, including stroke. We investigated whether comorbid psychiatric disease is associated with lower rates of CEA/CAS after stroke due to carotid stenosis.

Methods:
Ischemic stroke cases due to carotid artery disease were identified using ICD9-CM codes in the 2007-2011 Nationwide Inpatient Sample. Psychiatric disease was defined by ICD9-CM codes for secondary diagnoses of schizophrenia, bipolar disorder, depression, anxiety, or substance use disorders. Using logistic regression, we tested the association between psychiatric disease and CEA/CAS, controlling for demographic, clinical, and hospital factors.

Results:
In the 22,178 included stroke cases, CEA/CAS was used in 18.8% of those with, and 20.6% of those without, psychiatric disease (
p
=0.02). The presence of any psychiatric disease was associated with significantly lower odds of CEA/CAS (OR 0.84, 95% CI 0.76-0.94; Table 1). When diagnoses were analyzed separately, schizophrenia (OR 0.60, 95% CI 0.41-0.88) and substance use disorders (OR 0.76, 95% CI 0.63-0.91) were each associated with significantly lower odds of CEA/CAS. Moreover, the odds of CEA/CAS decreased as the number of psychiatric comorbidities increased: the presence of one comorbidity was associated with 13% lower odds of CEA/CAS (OR 0.87, 95% CI 0.78-0.98), while more than one comorbidity was associated with nearly 40% lower odds of CEA/CAS (OR 0.61, 95% CI 0.46-0.81), compared to those without any psychiatric disease.

Conclusions:
The odds of carotid revascularization after stroke due to carotid stenosis is lower in patients with psychiatric comorbidities, particularly in those with schizophrenia, substance use disorders, or multiple psychiatric diagnoses.
Abstract TP354: Usage of New Oral Anticoagulants Among Acute Ischemic Stroke Patients with Atrial Fibrillation in China: Findings from Chinese Stroke Center Alliance
Authors: Li Zixiao , Wang Yongjun , Wang Yilong , Zhao Xingquan , Gu Hongqiu , Yang Xi , Wang Chunjuan
Published: January 2019

Background and Purpose:
Previous studies have reported the underuse of warfarin for ischemic stroke patients with atrial fibrillation (AF) in China. New oral anticoagulants (NOACs) have become an efficacious alternative to warfarin and been recommended by guidelines. We sought to explore the usage of NOAs and affecting factors in China.

Methods:
From June 2015 to November 2017, 511 036 patients with acute stroke/TIA were admitted to 1 624 hospitals voluntarily participating in the China Stroke Center Alliance (CSCA), an ongoing, national, hospital-based, multicenter, stroke care quality registry and improvement program. Multivariable logistic regression models using the generalized estimating equation method were used to identify patient/hospital factors independently associated with NOACs use during hospitalization.

Results:
Among 28 456 ischemic stroke patients with AF, only 798 (2.8%) received NOACs, 8 635 (30.3%) received traditional anticoagulants therapy, 18821 (66.1%) received antiplatelet drugs only. Among patients receiving traditional anticoagulants or NOACs, younger age, lower education level, lower income, rural basic medical insurance schemes, more severity, secondary hospital, Central or West China were associated with lower odds of receiving NOACs (Table 1).

Conclusions:
Ischemic stroke patients with AF are under treated with anticoagulant, especially with the usage of NOACs. Further efforts are needed to increase the prescription of NOACs and other anticoagulants.
Abstract TP356: Renal Function and In-Hospital Outcomes in Patients With Acute Cerebrovascular Disease: Results From Chinese Stroke Center Alliance
Authors: Xie Xuewei , Wang Xianwei , Li Zixiao , Zhenzhen Rao , Wang Yongjun
Published: January 2019

Background and Purpose:
To investigate the association of renal function with in-hospital death and recurrent stroke in patients with acute stroke.

Methods:
Data were from the Chinese Stroke Center Alliance (CSCA) with a sample of 511 036 patients. Baseline eGFR was calculated with the Chinese modification of CKD-EPI equation and categorized into 4 groups. Logistic regression models with generalized estimating equations were used to evaluate the risks for in-hospital death and recurrent stroke among eGFR categories with and without stratification for hypertension, diabetes mellitus (DM) and atrial fibrillation (AF). A cubic spline smoothing technique was used to interpolate the overall trend of risks through the range of eGFR.

Results:
Of 501 497 patients, 70.1% had an eGFR ≥90, 21.7% an eGFR 60 to 89, 4.1% an eGFR 45 to 59, 4.1% an eGFR<45 mL/min/1.73 m
2
. In-hospital death occurred in 3.0% of patients with an eGFR of <45, 1.5% an eGFR of 45 to 59, 0.9% an eGFR of 60 to 89, and 0.5% an eGFR ≥90. Recurrent stroke occurred in 7.6%, 7.2%, 6.5% and 5.9% respectively. Compared with eGFR ≥ 90, the adjusted odds ratios with 95% CI of eGFR <45, 45-59 and 60-90 were 3.97 (3.42-4.61), 1.95 (1.70-2.45) and 1.37 (1.22-1.53) for in-hospital death and 1.02 (0.94-1.11), 0.98 (0.91-1.06) and 0.98 (0.93-1.03) for recurrent stroke. A significantly statistical interaction between DM and categories of eGFR for stroke recurrent was identified (interaction
P
=0.001). The other results were almost consistent in stratified analyses by hypertension, DM or AF. There was a J-shaped relationship between eGFR and in-hospital death. A linear relationship was observed between eGFR and recurrent stroke.

Conclusions:
Low eGFR was associated with increased risk of all-cause mortality but not with recurrent stroke in patient with acute stroke.
Abstract TP359: Reducing Door-In-Door-Out Time for Stroke Using Failure Mode, Effects, and Criticality Analysis
Authors: Mendelson Scott J , Khorzad Rebeca , Barnard Amy , Richards Christopher , Jahromi Babak , Bernstein Richard , Prabhakaran Shyam
Published: January 2019

Background:
Shorter time from symptom onset to thrombectomy is associated with better stroke patient outcomes. Despite this urgency, stroke patients transferred from PSC to CSCs experience treatment delays of 1-2 hours.

Objective:
We aimed to reduce door-in-door-out (DIDO) times at a spoke PSC serviced by a telestroke CSC hub using failure mode, effects, and criticality analysis (FMECA) of the current state process of care, implementation of an improved workflow, and deployment of a HIPAA-compliant real-time communication technology to all service providers (including transport EMS).

Methods:
Process mapping and FMECA was used to identify and rank delays and opportunities for reducing DIDO times. Multidisciplinary teams involved in acute stroke patient evaluation, transfer, and treatment participated in moderated sessions at both the PSC and CSC. Resulting process maps were used to streamline processes of care as well as identify opportunity for implementing a real-time communication technology (Pulsara™). A streamlined workflow was adopted which included early simultaneous activation of transferring EMS with telestroke neurology, direct to CT care, standardized documentation handoff, and real-time communication between CSC stroke neurologists and spoke hospital nursing, pharmacy, and transferring EMS. DIDO was measured prospectively after implementation and compared to the previous year’s data.

Results:
Process mapping identified 6 issues impacting DIDO time: delay in symptom identification and stroke code activation, delay in door to CT time, delay in EMS handoff, delay in requesting transfer ambulance, delays in contacting multiple providers at CSC hub, and redundant communication between providers. Ten key changes were proposed and implemented. Prior to implementation, 28 stroke patients with an average DIDO of 269m (SD 112m) were transferred. To date following implementation, 7 patients were transferred with an average DIDO of 104m (SD 25m). Only 4% of patients had DIDO <100m pre-implementation while 43% had DIDO <100m post-implementation.

Conclusions:
Rigorous analysis of the transfer process and implementation of process improvements can reduce DIDO times for acute stroke patients in a hub-spoke telestroke system.
Abstract TP367: Dysphagia Screening Tool Validation Study
Authors: Bush Kelly K , Jones Brenda , Taylor Kathryn , Tompkins Erin , Williams Shannon , Amos Amy , Summers Samantha , Cook Kelsey , Jones Philip , Boutwell Christine
Published: January 2019

Introduction:
Dysphagia occurs in roughly 30 to 67% of stroke patients and can lead to significant complications, including aspiration with subsequent pneumonia. There has been a lack of agreement on a single effective dysphagia screening tool. The tool used in our institution was developed internally based on extensive literature review, and includes dysphagia screening items followed by a water challenge.

Hypothesis:
We suspected this dysphagia screening tool was performing well based on low rates of aspiration pneumonia in our stroke patients. The purpose of this study was to validate the dysphagia screening tool against gold standard video fluoroscopy (VF).

Methods:
This was a prospective study to determine the sensitivity and specificity of the dysphagia screening tool. Our enrollment goal was 300 patients with suspected ischemic stroke between December 2016 and January 2018. The primary nurse completed the routine dysphagia screen, and the sub-investigator performed a blinded simultaneous screen, followed by VF evaluation. We used a group sequential design with interim analyses every 30 patients to allow for early stopping. The primary hypothesis was sensitivity >85%, evaluated using a one-sided test of proportion at a study alpha level of 0.025.

Results:
At the second interim analysis, 34/61 patients were positive for dysphagia on VF, while only 19 were positive on the screening tool. Estimated sensitivity was 55.9% (95% CI 39.5-71.1%), with a p-value below the second-stage threshold of 0.000002. Therefore, we terminated the study at this point. Estimated specificity was 51.9% (95% CI 34.0-69.3%), and the concordance between examiners for dysphagia screening as 91.8%.

Conclusions:
This is a routinely used screening tool across multiple hospitals within this organization. The tool did not show adequate sensitivity or specificity compared against the gold standard. Despite the results, we continue to have low rates of aspiration pneumonia. It is possible that VF may overestimate dysphagia, or that subjective interpretation of dysphagia criteria with VF may complicate the results. In conclusion, due to inadequate sensitivity and specificity of the dysphagia screening tool, we terminated the study and recommended modification of the tool.
Abstract TP373: Post IV-Alteplase Hemorrhage Rates in Early vs. Delayed Treatment Window in a Multi-State Health System
Authors: Yanase Lisa R , Stuchiner Tamela , Lucas Lindsay , Corless Leslie , Baraban Elizabeth
Published: January 2019

Introduction:
Reported rates of symptomatic intracranial hemorrhage (sICH) following IV-alteplase (tPA) for acute ischemic stroke range from 2.4 to 6.4% in clinical trials, with even broader ranges in registries. The objective of this study was to examine rates of sICH following tPA, overall and in the <3 and 3-5 hour treatment windows, in a large health system ranging from critical access hospitals to comprehensive stroke centers, as there are sparse data comparing sICH rates by treatment window.

Methods:
Patients discharged from hospitals in a multi-state system between January 2009 and April 2018 with diagnosis of stroke and treated with tPA were selected for analysis. Patients with inpatient stroke, under age 18, receiving endovascular treatment or with incomplete data were excluded. Firth’s logistic regression was used to determine if patients receiving tPA in 3 to 5 hours from symptom onset were more likely to have sICH < 36 hours compared to those treated <3 hours from symptom onset, adjusting for age, admit NIHSS, and mode of arrival. Interactions were tested to determine if individual covariates had a moderating effect on sICH by treatment window.

Results:
There were 3,996 patient cases with complete data included in the analysis, with 17.8% (712) treated in the 3-5 hour window, 27 of whom were treated between 4.5 and 5 hours. Median NIHSS was 8.0 [interquartile range (IQR): 4.0, 15.0], median age was 72.0 [IQR: 60.0, 83.0], 49.0% (n=1,951) were female, and 78.6% (n=3141) arrived via EMS. The overall sICH rate was 3.3% (n=133). There was no difference in rate of sICH <36 hours by treatment window. Additional interactions also showed no difference.

Conclusions:
In a large health system, there was an overall low rate of symptomatic intracranial hemorrhage following alteplase administration and no increase in rate in the 3-5 hour treatment window.
Abstract TP376: Barriers and Facilitators to Obtaining the “New” Goal Blood Pressure for Patients With Ischemic Stroke - A Mixed Methods Analysis from the Veterans Health Administration
Authors: Sico Jason , Burrone Laura , Bottomley Sharon , Keefner Lisa , Ellimuttil Shaji , Ragunton Jan-Michael , Damush Teresa , Hurd Paul , Fenton Brenda T
Published: January 2019

Introduction:
The 2017 ACC/AHA updated hypertension guideline recommends a “new” goal blood pressure (BP) of <130/80 mmHg for stroke survivors. Little is known regarding the perceived barriers and facilitators to implementing this recommendation and whether Veterans Health Administration medical centers (VAMCs) routinely achieving this degree of post-stroke BP control.

Methods:
Chart review was conducted to determine the numbers of patients with hypertension who obtained ACC/AHA (i.e., <140/90 mmHg) and Joint National Committee (JNC)-8 recommended BP goals (i.e., 130/80 mmHg). Thematic analysis was performed on 27 semi-structured qualitative interviews with providers, hospital and clinic administrators, and quality improvement staff conducted February-April 2018 at two diverse VAMCs. Interviews were conducted prior to the start of a CAre Transition and Hypertension (CATcH) improvement intervention. Code descriptions of “opinions regarding ‘new’ BP guidelines,” “barriers to BP management,” and, “facilitators to BP management” were compared across sites and among providers. A multidisciplinary team conducted consensus-based coding of transcripts.

Results:
In the sixteen-months prior to the implementation of CATcH, facility-level pass rates for BP control were: 50% (18/36) patients at Site 1 and 64% (16/25) at Site 2 had obtained old goal BP, whereas 28% (10/36) at Site 1 and 20% (5/20) at Site 2 obtained new goal BP. Barriers and facilitators of bp management were identified at the patient-, provider-, and facility-levels (Table). Similar themes were seen across sites.

Conclusions:
Pre-intervention pass rates for bp need to improve. Multiple barriers and facilitators at the patient-, provider-, and systems-levels have been considered in designing the CATcH intervention, which seeks to incorporate the 2017 ACC/AHA hypertension guidelines into routine clinical care and improve on current facility-level performance.
Abstract TP380: Impact of Early Mobilization on 90-Day Outcomes in Thrombectomy Patients
Authors: Stuchiner Tamela L , Clark Diane , Lucas Lindsay , Robison John , Yanase Lisa
Published: January 2019

Introduction:
Early mobilization of ischemic stroke patients receiving IV alteplase (tPA) did not worsen 90-day outcome at two urban stroke centers in a prior study, but there are no studies evaluating outcomes of early mobilization after thrombectomy. The mobility protocol used in the previous study was also utilized to mobilize stroke patients receiving thrombectomy treatment at these two centers, once minimum number of hours for groin precautions was complete and the groin puncture site was stable. The objective of this study was to determine for post-thrombectomy patients mobilized within 24 hours, whether earlier mobilization worsened outcomes.

Methods:
Medical records of ischemic stroke patients receiving thrombectomy at two urban stroke centers between May 2013 and December 2017 were reviewed for early mobilization (within 24 hours of groin puncture). Patients who did not expire in hospital and had complete data were included in the analysis. Ordinal regression was used to determine if, with each hour delay in time first up, patients’ functional outcomes worsened at 90 days using the modified Rankin scale (mRS), adjusting for pre-symptom onset mRS, admission NIHSS, age, sex, and post-treatment thrombolysis in cerebral infarction (TICI) grade. The mRS at 90 days was categorized as no symptoms or no significant disability (0 - 1), mild or moderate disability (2 - 3), and severe disability or death (4 - 6).

Results:
Of 147 patients mobilized within 24 hours, 91 patients were included in the analysis. Overall, 51% (n=46) were female, 74% (n=67) had no disability prior to their stroke, mean age was 68.0 (±14.1), mean admission NIHSS was 15.9 (±6.7), and 85% (n=78) had a post treatment TICI score of 2b or greater. Median time first mobilized was 14.1 hours [interquartile range: 9.4, 19.1]. Ordinal regression showed no evidence that earlier mobilization had an effect on patient outcomes at 90 days, patients were neither worse or better by time first mobilized within the first 24 hours (p=.706).

Conclusions:
Ischemic stroke patients receiving thrombectomy were mobilized within 24 hours of groin puncture by the early mobility protocol. Patients experienced no impact on outcomes at 90 days by time first mobilized. This result may have been limited by small sample size.
Abstract TP395: Modeling Outcomes in Acute Ischemic Stroke Using Machine Learning Algorithms
Authors: Vargas Jan
Published: January 2019

Background:
With the growing ease of collecting and analyzing large quantities of data, machine learning algorithms have risen in prominence for the purposes of creating models that can discover previously hidden relationships between large amounts of data points, and which can then be used for classification and predictive tasks.

Methods:
A retrospective database of patients admitted with acute ischemic stroke at a single institution was reviewed. Patients with a modified Rankin Scale (mRS) at discharge and those who had not undergone mechanical thrombectomy were selected. Modified Rankin Scale was dichotomized into good (0 to 2) and bad (3 to 6). 18 total variables, including patient demographics and admission lab values, were selected as inputs. Feature selection was initially performed using boosted decision trees to select the five most salient variables. Patients missing data from these features were dropped. Several classifiers were ensembled together and trained using 10-fold stratified cross validation to determine the likelihood a patient would achieve a good or bad mRS at discharge. Each fold’s accuracy, ROC curve and area under the ROC curve were calculated, and then averaged together once cross validation was complete.

Results:
6,320 patients with the diagnosis of acute ischemic stroke from 2006 to 2018 were examined. Of these, only 3,387 had an mRS at discharge recorded, and 1,972 patients were not missing any data and were available for analysis. The most important variables were age, NIHSS on admission, ambulatory status prior to admission, IV tPA administration, and admission INR. The final ensembled model achieved an accuracy of 80.8%, with an AUC 0.88 +/- 0.02.

Conclusion:
By utilizing machine learning strategies, large sets of data can be analyzed to develop models which can help inform clinicians the likelihood of a patient’s good outcome. Additionally, by examining which features are the most salient to a model, previously un appreciated factors can be highlighted and further studied.
Abstract TP397: Cost Analysis of Implementing Standardized Stroke Patient Education Materials in a Large Five State Health System
Authors: Swearingen Natalie , Corless Leslie , Swann Jessica , Cox Kailey , Lada Diane , Baraban Elizabeth
Published: January 2019

Background:
Providing stroke patient education is a national quality core measure and required by all certified stroke programs. Stroke patient education booklets (SPEBs) can be developed by stroke programs or purchased from an external organization (EO). Certifying bodies require specific stroke education content, however organizations can decide on the development and maintenance of the material. The cost of production, maintenance and purchase in a large five state health system was found to be highly variable prompting an 18 month collaboration to standardize SPEBs across the health system.

Purpose:
Analyze SPEB cost for both before and after implementation of a standardized SPEB for a large five state health system.

Methods:
Stroke program coordinators/champions responsible for developing, maintaining, and ordering SPEBs for 18 facilities were surveyed as to cost and time spent managing SPEBs per year before and after SPEB implementation. Outliers were excluded.

Results:
Surveys were sent to 18 stroke program coordinators/champions representing 18 facilities with responses received from 17 facilities (94.4% response rate). Facilities reported time spent producing or managing the SPEBs ranged from 2 to 60 hours, averaging 27 hours per year. The anticipated time that will be spent producing or managing SPEBs after standardization was between 0 and 32 hours with an average of 8.86 hours per year. Cost of production for the pre standardization SPEB ranged from $.73 to $15.00 per SPEB with an average of $5.18. The cost of post standardization SPEB production was lower for all facilities and ranged from $0.38-$14.62, with an average savings of $4.80 per SPEB.

Conclusions:
Stroke program production, development and maintenance of SPEBs cost time and money. An 18-month system wide collaboration for standardization of the SPEB significantly decreased cost per SPEB to all hospital sites within the large five state health system. Implementation of standardized SPEBs can save facilities thousands of dollars per year.
Abstract TP403: Blood Pressure Reduction on Two-Year Mortality and Major Disability in Patients With Acute Ischemic Stroke According to Time to Treatment
Authors: Chen Jing , Zhang Yonghong , Xu Tan , Wang Dali , Chen Chung-Shiuan , Sun Yingxian , He Jiang ,   the CATIS investigators
Published: January 2019

Introduction:
The optimal time to initiate antihypertensive therapy among patients with acute ischemic stroke remains uncertain. We tested the effects of blood pressure (BP) reduction on two-year mortality and major disability in acute ischemic stroke patients according to time from onset to initiation of antihypertensive treatment.

Methods:
The China Antihypertensive Trial in Acute Ischemic Stroke, a randomized, single-blind, blinded end-points trial, was conducted in 4,071 patients with ischemic stroke within 48 hours of onset and elevated systolic BP (SBP). Patients were randomly assigned to receive antihypertensive treatment (n=2,038) or to discontinue all antihypertensive medications (n=2,033) during hospitalization. Post-treatment follow-ups were conducted at 3, 12, and 24 months after hospital discharge. The primary outcome was a composite of death and major disability at the two-year follow-up visit.

Results:
At 24 hours after randomization, the differences in SBP reductions were 8.7, 9.5, and 9.6 mmHg between the antihypertensive treatment and control groups among patients receiving treatment within less than 12, 12-23, and 24-48 hours after stroke onset, respectively (P<0.001 in all subgroups). At two-year follow-up, study outcomes were obtained in 1,945 (95.4%) participants in the treatment group and 1,925 (94.7%) in the control group. The event rates of primary outcome were not statistically significantly different between the antihypertensive treatment group and the control group according to time to treatment (Table).

Conclusions:
Among patients with acute ischemic stroke, BP reduction with antihypertensive medications during hospitalization did not reduce or increase the composite outcome of death and major disability over two years according to time to initiation of treatment.