bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P166: Is Functional Disability after an Index Stroke a Risk Factor for Recurrent Vascular Events?
Authors: Park Jong-Ho , Ovbiagele Bruce
Published: July 2021

Background:
The modified Rankin Scale (mRS) is widely used as an index for measuring degree of functional disability following a recent stroke. However, greater degree of disability after stroke may unfavorably influence adherence to recommended medical and lifestyle practices shown to lower recurrent vascular event risk. We are unaware of published studies that have examined the possible association of post-stroke disability with occurrence of future vascular events.

Methods:
We reviewed the dataset of a multicenter trial involving 3680 recent non-cardioembolic stroke patients aged ≥35 years and followed for 2 years. Independent associations of post-stroke disability (as measured by modified Rankin Scale [mRS] score) with recurrent stroke (primary outcome), stroke, coronary heart disease (CHD), or vascular death as major vascular events (secondary outcome), and all-cause death (tertiary outcome) were analyzed. mRS score was analyzed as a dichotomous (≥2 vs. ≤1) and a dose dependent manner.

Results:
Among study participants, 1336 (36.3%) had a baseline mRS ≥2 (overall scores ranged from 0 to 3). Baseline mRS was measured at a median 35 days after the index stroke. Compared to mRS ≤1, mRS ≥2 was associated with higher risk of recurrent stroke (HR 1.26, 95% CI: 0.99-1.60), major vascular events (HR 1.17; 95% CI: 0.98–1.38), and all-cause death (HR 1.62; 95% CI: 1.21–2.16). Compared with mRS 0, there was progressively higher risk for stroke: mRS 1 (HR 1.40; 95% CI, 0.97-2.01), mRS 2 (HR 1.45; 95% CI, 0.98-2.14), mRS 3 (HR 1.99; 95% CI, 1.30-3.05). Compared with mRS 0, there was progressively higher risk for major vascular events: mRS 1 (HR 1.26; 95% CI, 0.99-1.61), mRS 2 (HR 1.30; 95% CI, 1.00-1.69), mRS 3 (HR 1.55 (95% CI, 1.15-2.09). Compared with mRS 0, there was progressively higher risk for all-cause death: mRS 1 (HR 1.50; 95% CI, 0.94-2.39), mRS 2 (HR 2.06; 95% CI, 1.27-3.35), mRS 3 (HR 2.41; 95% CI, 1.42-4.09).

Conclusions:
Greater functional disability after a recent stroke is linked to a higher risk of recurrent vascular events including stroke and all-cause death. Future studies with a wider range of mRS are needed to confirm this relationship and to clarify its underlying mechanisms.
Abstract T P176: Classification of DWI Lesion Patterns in Acute Ischemic Stroke Using Shape Context
Authors: Scalzo Fabien , Liu Dezhi , Liebeskind David S
Published: July 2021

Introduction:
Neuroimaging studies in ischemic stroke hold abundant features about location, type, and extent of brain ischemia. Identification of imaging characteristics that predict recovery of brain tissue at risk remains an ongoing effort and such DWI patterns hold promise. However, systematic analysis of large multi-modal datasets face many challenges. An automated algorithm for classification of DWI lesion patterns in real-time would be ideal. We developed and evaluated a computer vision model that uses 3D shape description of the lesion for classification of DWI lesion patterns into an existing nomenclature.

Methods:
Inclusion criteria were acute ischemic stroke and DWI performed within 24 hours of symptom onset. Acute lesions were manually segmented on DWI and categorized into 6 types (territorial, other cortical, small superficial, internal border zone, small deep, and other deep infarcts). The computer vision model characterized stroke lesion using a shape context descriptor that accumulates surface points of the lesion into a 3D log-linear spherical histogram. The experiments estimate the accuracy of the model in classifying the lesion patterns using a leave-one-out cross-validation.

Results:
A total of 344 patients satisfied inclusion criteria. Mean age was 66.1 (range 13-97). Median NIHSS at baseline was 14 (range 0-38). Average lesion volume was 75.6 cc (range 5-256). The number of observations per category was [territorial:81, other cortical:51, small superficial:78, internal border zone:12, small deep:34, other deep infarcts:88]. When combining lesion volume, average location relative to the center of the brain, and shape descriptor as input, the classification models yielded perfect classification accuracy over the entire dataset.

Conclusions:
An advanced computer vision framework that automatically identifies discriminant features between lesion categories was introduced and successfully evaluated on 344 patients with acute stroke. Our study enables even larger scale retrospective analyses. Computer vision and pattern recognition methods can play a central role for the systematic analysis of big data in stroke.
Abstract T P177: Non-dominant Vertebral Artery With Higher Resistance Flow Pattern Is A Risk Factor For Ischemic Stroke
Authors: yeo Leonard , Batra Amit , Tan Ashley , Majinyang Song , Low Darren , Sharma Vijay
Published: July 2021

Background and aims:
The diameters of the vertebral arteries (VAs) are very often unequal and the larger artery is called ‘dominant’. We investigated whether the hemodynamic parameters differ between the ‘dominant’ and ‘non-dominant’ variants.

Methods:
Consecutive patients who underwent computed tomographic angiography (CTA) of cervical and intracranial arteries, cervical duplex (CDU) and transcranial Doppler (TCD) ultrasonography were included. VA diameters (cervical and intracranial segments) were measured on CTA. Flow velocities recorded were peak systolic (PSV), end-diastolic (EDV), mean flow (MFV). Pulsatility index (PI) and ratio of distal-to-proximal VAs were computed.

Results:
Of the total 501 patients admitted during 2012 with acute ischemic stroke, both CTA and ultrasound data were available for VAs for 161 (32%). The dominant VA was more frequent on the left side (p<0.01). Non-dominant VAs were found to have lower MFV (27cm/s versus 38cm/s; p<0.01) and higher PI (1.27 versus 1.0; p<0.01) as compared to the dominant variant. In most patients, proximal basilar artery was noted to be on the side of non-dominant artery. Posterior inferior cerebellar artery territory infarcts and lateral medullary infarcts were noted in 38 (7.6%) patients. These infarcts were noted more commonly on the same side as the non-dominant intracranial VA side (p<0.01), especially when associated with low MFV (p<0.01) and high PI (p<0.01).

Conclusions:
The risk of ischemic stroke in VA territory is higher with the non-dominant artery, especially when it is associated with higher-resistance flow pattern.
Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy
Authors: Gulati Deepak , Aghaebrahim, Amin , Malik Amer , Ducruet Andrew , Jankowitz Brian , Jovin Tudor , Jadhav Ashutosh
Published: July 2021

BACKGROUND:
Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation.

METHODS:
Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%).

RESULTS:
A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient.

CONCLUSION:
Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control.
Abstract T P181: Static And Dynamic Cerebral Autoregulation Dissociate In Asymptomatic Carotid Artery Disease
Authors: Marshall Randolph S , Lazar Ronald M , Pavol MaryKay A , Dharssi Shazia , Qiu Yujie , Slane Kevin , Asllani Iris
Published: July 2021

Background:
High grade internal carotid artery (ICA) disease can alter cerebral autoregulation and thus increase risk for ischemia. We aimed to differentiate two types of autoregulation - dynamic cerebral autoregulation (DCA), thought to be a homeostatic process, and vasomotor reactivity (VMR), which determines cerebrovascular reserve - in patients with asymptomatic ICA stenosis.

Methods:
Twenty-two patients (age 50-93, 16M) with unilateral 80-100% ICA occlusion but no stroke underwent quantitative CBF measurements using continuous arterial spin labeling (CASL) MRI. DCA was performed by continuous insonation of both middle cerebral arteries with transcranial Doppler for 10 minutes at depth 56mm using a standard head frame. Phase shift (PS) between spontaneous oscillations in blood pressure (measured with finger photoplethysmography (Finapres)) and MCA mean flow velocities (MFV) at frequencies .06-.12 Hz was calculated for each hemisphere using transfer function analysis. Lower degree of PS indicated worse autoregulation (abnormal <24deg1). VMR was determined as a response to 2 minutes of 5% CO2 inhalation (abnormal <2% rise in MCA MFV per mmHg PCO2 by Doppler-integrated inline capnometer (Spencer Technologies)). T-test Chi-square, and multivariable linear regression were used to look for associations between VMR, DCA, and hemispheral CBF (SPSS v.22).

Results:
MCA MFV (p<.001), VMR (p=.002), and CBF (p<.003), were lower in the ICA occlusion hemisphere. DCA difference approached significance (p=0.064). Controlling for age and anterior circle of Willis collateral cross-filling, DCA (p=0.024), but not VMR (p=0.079) on the occluded side was associated with greater hemispheral CBF asymmetry (F=6.87, p=0.024). VMR and DCA were not correlated (Fisher exact =.61).

Conclusions:
DCA but not VMR correlated with a low flow state produced by high grade ICA disease in asymptomatic patients. Our results suggest that in ICA stenosis dynamic/homeostatic mechanisms may be affected without substantially altering the static/protective mechanism of cerebrovascular reserve. Ongoing studies will investigate the effect of these two autoregulatory mechanisms on vascular cognitive impairment.

1 Ortega-Gutierrez S, et al. J Neuroimaging. 2014 24:379-86
Abstract T P199: An External Network Validation of the TeleStroke Mimic Score: A Prediction Rule for Identifying Stroke Mimics Evaluated during Telestroke Encounters
Authors: Ali Syed F , Majersik Jennifer J , Shepard L. Wylie , Viswanathan Anand , Cohen Adam , Schwamm Lee H
Published: July 2021

Introduction:
Up to 30% of acute stroke evaluations are deemed stroke mimics, and these are common in telestroke as well. We recently published our risk prediction score for use during telestroke encounters to differentiate telestroke mimics (SM) from ischemic cerebrovascular disease (iCVD). Using data from the University of Utah Telestroke Program, we sought to externally validate the TM score.

Methods:
We evaluated the TM risk score in 190 telestroke consults performed at the University of Utah Telestroke Program from Nov 2010 to Jun 2014 by use of ROC curve analysis. The TM score = (Age multiplied by 0.2) + 6 (Hx of atrial fib) + 3 (Hx of HTN) + 9 (facial weakness) + 5 (NIHSS > 14) - 6 (Hx of seizure). Lower TM scores yield higher chances of being a stroke mimic.

Results:
Based on final clinical diagnosis, there were 86/190 (45.3%) SM in the external validation cohort. We tested only those characteristics that were previously shown to be associated with SM through inclusion in the TM score (Table 1). Of the 6 TM elements, 3 items were not significantly different between SM and iCVD (A. Fib, hypertension and age). Despite this, the TM Score validated well on ROC curve analysis with AUC of 0.70, similar to what was reported during the development and validation of the score at our center.

Conclusion:
As telestroke consultation expands, increasing numbers of SM patients are being evaluated. These patients differ substantially from their iCVD counterparts in their vascular risk profiles and other characteristics. Decision-support tools based on predictive models may help highlight these differences during complex, time-critical telestroke evaluations. Further validation is desirable.
Abstract T P210: Budget Impact Analysis (BIA) of Telestroke in the Pacific Northwest
Authors: Nelson Richard , Lesko Alexandra , Majersik Jennifer , Okon Nicholas , Baraban Elizabeth
Published: July 2021

Background:
Assessed from the budget holder’s perspective over a short-term time horizon, a budget impact analysis (BIA) is an economic assessment that estimates the financial consequences on local budgets of adopting a new intervention. To date, BIA has not been published specific to telestroke.

Objective:
We conducted a BIA of a telestroke network using patient- and system-level data from the Providence Telestroke Network (PTN) to assess overall financial impact.

Methods:
We modeled the care of a patient with acute ischemic stroke (AIS) presenting to a spoke hospital. Patient-level inputs (IV tPA usage; spoke admission vs. transfer to hub; mortality; and discharge to a rehab facility, skilled nursing facility, or home) were used to populate a decision analytic model from before and after telestroke implementation. We used patient-level cost data by NIHSS to obtain mean costs by patient type, and modeled cost per patient from spoke and hub perspectives, if the spoke hospital was or was not part of PTN. We used the mean number of AIS patients seen at PTN spokes per year (n=14.4) and the number of PTN spokes (n=17) to generate the budget impact of telestroke on the individual spoke, all spokes combined, and the hub.

Results:
BIA results are presented in Table 1 by time period (12, 24, and 36 months) and proportions of telestroke implementation costs paid for by the spoke facility (0%, 50%, and 100%).

Conclusions:
Our results suggest that telestroke may lead to a decrease in overall cost from the spoke facility perspective even if the spoke facility is responsible for half of the telestroke implementation costs. While complementing prior telestroke cost-effectiveness analyses, the results from this BIA can assist decision makers at community hospitals who are considering joining a telestroke network by demonstrating the impact that it would have on the hospital’s bottom line.
Abstract T P242: Cognitive Dysfunction in a Pre-chiasmatic Cistern Blood Injection Model of Aneurysmal Subarachnoid Hemorrhage In Mice
Authors: Oka Fumiaki , Atalay Yahya B , Qin Tao , Ayata Cenk
Published: July 2021

Background:
Majority of aneurysmal subarachnoid hemorrhage (SAH) survivors develop cognitive dysfunction. To better understand the underlying mechanisms and develop treatments, predictive animal models are required. We carried out a detailed physiological and cognitive characterization of pre-chiasmatic cistern (PC) and cisterna magna (CM) SAH models in mice.

Methods:
SAH was induced by arterial blood injection into the PC (40 μl) or CM (60 μl) in C57BL6/J mice (male, 25g). Controls received normal saline. Cerebral blood flow (CBF) was imaged using laser speckle flowmetry during and for 60 min after SAH. Intracranial pressure (ICP) and blood pressure (BP) were monitored to calculate cerebral perfusion pressure (CPP). Neurological and cognitive function was assessed 3 weeks after the injection, using pole, novel object recognition, Y maze and Morris water maze tests.

Results:
Mortality was 10% after PC and 4% after CM SAH. In both groups, CPP decreased from about 65 mmHg to less than 10 mmHg immediately after the injection, and recovered to 40 mmHg within 10 min after PC (n=8) and 7 min after CM (n=8) SAH (Fig A). In both groups, CBF was severely reduced to ~20% of baseline in both hemispheres immediately after SAH. CBF recovered to >40% within 5 min after PC and 2 min after CM SAH (Fig A). In saline controls (n=5 in PC and CM each), CPP and CBF changes were much milder and shorter-lasting. Compared with controls (n=12), PC SAH mice (n=12) performed significantly worse in a subset of sensorimotor and cognitive tests for up to 3 weeks (Fig B). CM SAH did not significantly impact neurological function.

Conclusions:
Pre-chiasmatic cistern but not cisterna magna SAH model reproduces cognitive dysfunction observed in patients with low mortality and high reproducibility in mice.
Abstract T P263: Screening Practices for Sleep-Disordered Breathing in Stroke Medical Community
Authors: Navalkele Digvijaya , Barlinn Kristian , Chernyshev Oleg
Published: July 2021

Background:
Frequency of sleep-disordered breathing (SDB) among stroke and TIA patients ranges from 50% to 94%, and is associated with poor neurological outcomes. Per current stroke prevention guidelines from American Stroke Association, SDB is included in the list of modifiable risk factors for stroke and TIA prevention. The goal of our study was to determine screening practices for SDB in stroke medical community.

Methods:
A web-based survey was conducted between 12/2013 to 7/2014 among practitioners taking care of stroke patients across United States and Europe.

Results:
Among 112 total responses (18%), 91 were stroke physicians (81.25%), 9 were general neurologist (8.04%), 3 were sleep medicine physicians (2.68%) and 9 were other specialty (8.04%). Majority of practitioners (72%, n= 81) do not use SDB screening questionnaires in their stroke patients. Epworth sleepiness scale is the most used among SDB questionnaires (24%), followed by Berlin sleep questionnaire (9.5%) and STOP-BANG questionnaire (7%). Only 12% of practitioners use screening questionnaires in both in-patients and out- patients, where as 20% use only in out- patients and 5% use only in acute stroke setting. Only 50% of practitioners would refer their stroke patients to a sleep medicine specialist when patients were screened positive for SDB on questionnaires.

Conclusion:
Despite being an independent risk factor for stroke and TIA, majority of practitioners do not screen stroke and TIA patients for SDB. Further work is needed to improve screening practices for SDB in stroke medical community.
Abstract T P268: Medication Persistence and Risk for Hospital Readmission in Stroke Patients
Authors: Han Sangwon , Arnan Martinson , Bushnell Cheryl
Published: July 2021

Background/Objectives:
In patients with stroke/TIA, low persistence with hypertension medications increases the risk of stroke recurrence, but there is limited information on medication persistence and readmission. Our aim was to determine whether secondary prevention medication persistence after discharge was associated with readmission at 30 and 90 days in stroke patients.

Methods:
We enrolled patients discharged home with ischemic (IS) or hemorrhagic stroke (HS) or TIA from October 2012 to February 2014 in the TRAnsition Coaching for Stroke (TRACS). Patients were contacted by telephone between 2 and 30 days for coaching, and 90 days after hospital discharge for outcomes. Medications at discharge were compared to those after discharge by phone or follow-up clinic visit to ascertain stroke prevention medication persistence. Readmission was ascertained using the medical records at the discharge hospital. Statistical tests were performed to assess factors associated with medication persistence and also with all cause and stroke readmission at 30 and 90 days.

Results:
A total of 142 patients were enrolled (108 IS, 13 HS, and 21 TIA patients); mean age 63.6 ± 13.1 yrs and 52.8% women. Overall medication persistence was 80.3% at 3 months. All cause readmission (ACR) at 30 days was 8.5% (n=12); 4.2% (n=6) due to recurrent stroke/TIA (STR). ACR at 90 days was 18.3% (n=26); 7.0% (n=10) with STR. Multivariate logistic regression model showed that prior hospitalization was associated with ACR at 30 days and CAD, and female sex with ACR at 90 days (Table). Prior stroke was associated with STR at 30 and 90 days (Table). There was a trend toward lower medication persistence (60.0% vs 81.8%, p=0.095) in those with STR at 90 days.

Conclusions:
In patients discharged with stroke, women and patients with CAD are at risk for ACR and those with prior stroke are at risk for STR, which represents the 3rd event. Poor secondary prevention medication persistence may be a potential risk factor for STR.
Abstract T P27: Early Blood Brain Barrier Disruption in the Ischemic Core
Authors: Leigh Richard
Published: July 2021

Background:
Animal models of cerebral ischemia have identified an early, reversible opening of the blood brain barrier (BBB) which is separate from the delayed secondary opening caused by neuroinflamation. A recent study found BBB disruption was frequently detected in acute ischemic stroke patients with MRI permeability imaging (Leigh et al., Stroke, 2014).

Hypothesis:
More severe restricted diffusion will be associated with higher degrees of BBB damage in acute ischemic stroke patients.

Methods:
The MRI scans of 13 acute ischemic stroke patients were analyzed. Diffusion weighted images (DWI) and perfusion weighted images (PWI) where co-registered to allow for a voxel based analysis. Blood-brain permeability images (BBPI) were generated from the PWI source images as described in the aforementioned study. Only voxels of tissue which had an apparent diffusion coefficient (ADC) < 700 were included. Linear regression was performed to determine if there was a relationship between ADC and BBPI.

Results:
From the 13 patients, 535 mL of brain tissue was included in the analysis. The figure shows a scatter plot and regression line of ADC value vs mean fraction of gadolinium leakage on BBPI. Univariate linear regression with ADC as the independent variable and BBPI as the dependent variable found them to be significantly correlated (p<0.001). Multivariate analysis found time-to-MRI (p<0.001) but not patient age (p=0.71) to be significantly correlated with BBPI in addition to ADC (p<0.001).

Conclusions:
Early BBB damage was detected within the ischemic core of acute stroke patients. The degree of restricted diffusion was significantly correlated with the degree of BBB damage.
Abstract T P284: Trends in Ontario’s Stroke Report Cards
Authors: Hall Ruth , Linkewich Elizabeth , Khan Ferhana , Wu Jianbao , Moore Patrick , O’Callaghan Christina
Published: July 2021

Background:
In 2011, the Ontario Stroke Evaluation and Quality Committee created Ontario’s Stroke Report Card, consisting of twenty indicators with potential to influence system performance and flow of stroke patients across the care continuum. The provincial report card and 14 regional report cards serve as a valuable stakeholder tool that allows for consistent planning across the province.

Purpose:
To evaluate stroke system performance at the provincial and regional level by comparing recent performance to previous three-year performance.

Methods:
Indicator performance was analyzed at the LHIN and provincial levels for 19 of 20 indicators with available data.

Statistical significance was determined by comparing the most recent year’s performance to the combined average of the previous three years performance. A chi-square test, Wilcoxon rank-sum test, and Poisson and logistic regressions were used where appropriate. Eight indicators used FY2004/05, FY2008/09, FY2010/11 and FY2012/13 Ontario Stroke Audit of acute care facilities data and eleven used FY2009/10-FY2012/13 Canadian Institute for Health Information administrative databases and one used the Ontario Home Care Database, FY2008/09-FY2012/13.

Results:
In Ontario, 15 of 19 indicators showed statistically significant improvement from the previous 3 years. Only one indicator showed a statistically significant decline and the remaining three indicators improved but were non-significant (p > 0.05). Among the regional report cards, the number of indicators with statistical significant improvement ranged from 3-10 and 0-2 with statistical significant decline.

Conclusion:
The stroke report cards reflect steady improvement in stroke prevention, acute management and rehabilitation in Ontario. These improvements are in the absence of financial incentives such as pay for performance suggesting there is great capacity for the health system to improve using targeted performance reports.
Abstract T P286: Telephone Support Program Promotes Stroke Survivor Knowledge, Self-Care, and Satisfaction
Authors: Lundy Yulonda D , Song Sarah Y
Published: July 2021

Background and Issues:
Stroke is the fourth leading cause of death, and the leading cause of disability. Aside from physically disablement, stroke survivors often experience difficulty coping with life post-discharge. Knowledge of stroke symptoms is often low, even in patients who have suffered stroke. Programs designed to provide support and education to stroke survivors can be effective at promoting stroke knowledge and improving patient satisfaction.

Purpose:
To evaluate the effectiveness of a telephone support program at promoting stroke knowledge, coping and self-care in stroke survivors.

Methods:
The Rush Stroke Buddy Program was developed in 2011 to provide support for patients with ischemic and hemorrhagic stroke after discharge from Rush University Medical Center. The telephone program consists of monthly calls to patients who voluntarily enlist in the program. Each phone call has two facilitators, a nursing student (“Buddy”) and a stroke survivor (“Ambassador”), who are undergo intensive training including lectures given by a rehab physician, a behavioral psychologist, a spiritual care worker, a social worker, and a nurse educator. Each phone call follows protocol: the Buddy is responsible for discussing aspects of stroke symptom education, personal medical risk factor reduction, and reviewing medications; the Ambassador provides emotional support for the stroke survivor.

Results:
Of 34 active participants since program inception, 17 (50%) agreed to be surveyed. 15 subjects (88%) felt the program empowered them to manage their health, addressed concerns, and helped them cope (94%). 13 subjects (76%) stated the program helped them overcome difficulties. All participants could name at least one stroke symptom; 14 subjects (82%) could name two or more. 13 subjects (76%) felt they better understood their medicines; 16 subjects (94%) felt they understood when to seek urgent medical attention. Sixteen subjects (94%) stated they would recommend the program to others.

Conclusions:
The Rush Stroke Buddy Program provides stroke survivor satisfaction, reinforces stroke symptom knowledge, and provides emotional support. Although further research is needed on stroke support, this program overall improves patient coping, self-care and education.
Abstract T P287: The Utility of Depression Screening in the Acute Stroke Hospitalization
Authors: Shankar Lakshmi , Smith Nicole , Uchino Ken , Thompson Nicolas , Katzan Irene
Published: July 2021

Background:
The importance of early recognition and treatment of post stroke depression (PSD) has led to recommendations for depression screening during the acute stroke admission.

We studied the utility of PSD screening during acute stroke admissions using the 2-item Patient Health Questionnaire (PHQ-2) by (a) determining the prevalence of positive depression screen during admission and (b) calculating the level of agreement between positive screens during admission and outpatient follow-up.

Methods:
This was a retrospective cohort study of adult patients discharged 1/2013 - 12/2013 with principal discharge diagnosis of acute ischemic stroke or intracerebral hemorrhage excluding patients who died during admission. PSD screening was systematically performed using the 4-item PHQ (PHQ-4) administered to patients on the stroke service by midlevel providers. Positive screen was defined as PHQ-2 subscore ≥3. At outpatient follow up, the 9-item PHQ (PHQ-9) was administered by patient questionnaire.

Results:
Of 718 patients, acute phase PHQ-4 data was available for 50% (358), 14% were not assessed due to drowsiness or aphasia, 2% were both admitted and discharged on weekends, and 21% were admitted to non-stroke services. Demographic characteristics were similar between the groups with and without PHQ data with higher rates of hemorrhagic strokes, longer ICU stay, and worse discharge mRS in the group without PHQ data. The median time from admission to PHQ-4 was 3 days. The screen was positive in 4.7% (17/358, 95% CI 2.8% - 7.5%). Outpatient follow-up occurred in 55% (396/718) patients a median of 34 days postdischarge and 260 had PHQ-9 data. Of these, 20.8% (54/260, 95% CI 16.0% - 26.2%) screened positive using PHQ-2.

There were 158 patients who had PHQ-2 data from both acute and follow up phases, 1.9% (3/158) of these screened positive in the acute phase and an additional 15.8% (25/158) who screened negative in the acute phase converted to positive at follow up.

Conclusion:
Systematic screening for PSD using PHQ-2 in acute phase of stroke identified few patients with depression and there was subsequent conversion to a positive screen at follow up. PSD screening in acute in-hospital phase does not appear to be cost efficient utilization of inpatient resources.
Abstract T P298: Impact of Accurate Weight Based Dosing of IV tPA in Acute Ischemic Stroke Patients
Authors: Jani Vishal B , Lahewala Sopan , Arora Shilpkumar , Shell Erin , Razak Anmar , Maaz Abraham , Cai Liqian , He Tao , Sachdeva Gautam , Morgan Larry , Safdar Adnan , Mitchell Marylou , Bey Julie , Hussain Syed
Published: July 2021

Background:
Accurate weight-based dosing is essential for efficacy and safety of thrombolysis in acute ischemic stroke (AIS). Stroke patients may be unable to communicate correct body weight (BW). Dosing may be estimated which can lead to error.

Objective:
To assess accuracy of weight estimation and the effect of weight and dosing discrepancy on outcome of patients with AIS

Methods:
94 patients receiving IV tpa for AIS in a CSC registry between Feb, 2013 and Jul, 2014 were reviewed. All were given estimated weight based tPA- per patient input or agreement of 2 providers in ER. Accurate weights were obtained and recorded later. Actual weight was used to calculate the ideal TPA doses and compared to the weights and doses used. The cohort was separated into two groups based on weight discrepancy to those 10 kg (non forgiven) discrepancy. Rate of hemorrhage, NIHSS and hospice/mortality were assessed. Difference between categorical variables was tested using the chi-square and Fisher’ Exact Test. Differences between continuous variables were tested using Wilcoxon Rank Sum test and presented with median and IQ range.

Results:
86.1% (forgiven cohort) were given the optimal tPA dose despite estimation. There was a significant difference in stroke severity based on admission NIHSS between the cohorts (33.3% in forgiven vs. 69.2% non-forgiven. P=0.04). Stroke severity based on discharge NIHSS did not reach statistical significance (mild: 71.8% vs 63.6%, moderate: 16.9% vs 9.1% and severe: 11.3% vs 27.3%, p = 0.32). 30 days modified Rankin Scale (mRS) was available for 52 pts without any significant difference (good outcome 44.4% vs 57.1%, poor outcome 35.6 % vs 28.6 %, p = 0.82). Statistically non significance toward higher rate of hemorrhagic conversion (6.4% vs 7.7%, p = 0.41), and higher mortality in non-forgiven group (7.41% vs 15.38%, p= 0.33).

Conclusion:
Accurate BW measurement prior tPA still remains challenging. In this study, weight estimation by 2 providers is fairly accurate. 14 % of the patients with discrepancy of > 10 kg had higher rate of mortality and hemorrhage although this was not statistically significant. Further studies with larger sample sizes are needed to examine the safety of weight estimation in AIS patients who receive IV tpa
Abstract T P303: Early Mobility after Thrombolysis for Stroke is Safe and Improves Outcomes
Authors: Yanase Lisa R , Stuchiner Tamela , Baraban Elizabeth , Clark Diane
Published: July 2021

Purpose:
To evaluate safety and outcome of mobilizing patients to their functional ability within 24 hours of receiving thrombolytic therapy (IV tPA) for stroke at two Primary Stroke Centers.

Background:
Bed rest for 24 hours after tPA for stroke is the national standard of care, though there are no data to support this practice. Additionally, tPA patients are not typically mobilized early due to a perceived risk of increased complication or falls. However, data show that early mobility in other critical care populations improves outcomes and shortens length of stay (LOS). Studies to date among tPA-treated patients suggest favorable outcomes but with small clinical trial data.

Methods:
A validated Stroke Early Mobility Assessment Protocol was implemented within 24 hours in all patients receiving tPA for stroke and mobilizing them to their highest functionally safe level. Data from pre (Jan 2009-June 2012) and post (July 2012-March 2014) implementation were compared for safety and outcome, including complications, falls, discharge destination, and LOS. Chi square and t-tests were used to determine significant differences in outcomes before and after implementation.

Results:
Between 2009 and 2014, 331 stroke patients received tPA (177 pre-implementation and 154 post). Among those receiving tPA after implementation, 129 were mobilized per protocol, 16 were not, and 8 were placed on comfort care. There were no falls among tPA patients pre or post implementation. Post implementation patients mobilized early were more likely to be discharged home, 56.5% vs. 40.1%, and less likely to expire or discharge to hospice, 9.6% vs 4.5% (p<0.01). There was no significant change in symptomatic hemorrhagic complications or LOS.

Conclusion:
Using a validated protocol, early mobilization of patients after tPA does not cause an increase in falls or neurologic or other complications. Early mobilization may improve the likelihood of discharge to home and reduce in-hospital mortality, but does not change LOS. Future analyses will include multivariate models to determine the direct relationship between early mobilization and outcomes among ICU patients receiving tPA.
Abstract T P312: Utility of Early MRI in Intracerebral Hemorrhage
Authors: Braksick Sherri A , Hocker Sara
Published: July 2021

Introduction:
Intracerebral hemorrhage (ICH) causes significant morbidity and mortality. Utility of early magnetic resonance imaging (MRI) is not fully understood. Identifying patients in whom early MRI changes clinical management may improve outcomes in select patients and reduce costs overall by avoiding inpatient MRIs in patients who are unlikely to benefit.

Hypothesis:
We assessed the hypothesis that early MRI in patients with spontaneous ICH does not alter management acutely in older patients.

Methods:
We conducted a retrospective chart review of all ICH admitted to our institution from 2006-2012. Patients were excluded if they 1) had a known underlying lesion, 2) were < 18 years, 3) suffered ICH as a result of trauma or 4) did not undergo MRI. Data were evaluated for clinical or radiographic characteristics that resulted in a change in clinical management, including surgical intervention or future avoidance of antithrombotic medications, among others.

Results:
In total, 248 patients with a median age of 70 years (IQR 58-78) were included. MRI changed management in 79 patients (31.9%). Initial MRI was obtained an average of 10 days after the hemorrhage. Possible structural abnormalities requiring emergent intervention were found in 14 (17.7%) patients, while 64 (81.0%) had findings concerning for other non-emergent/non-surgical anomalies (possible tumor (n=6), cavernoma (n=7), alternate diagnosis (n=1), probable amyloid angiopathy (n=21), evaluation for embolic phenomenon (n=13), evaluation for vasculitis (n=2), abnormal edema/enhancement (n=8), MRI led to additional non-invasive vascular imaging (n=6)). One patient (1.3%) was found to have a venous sinus thrombosis prompting anticoagulation. MRI was more likely to result in a change in management in patients < 55 years of age (47.1% vs 27.9%, p=0.009).

Conclusions:
MRI after ICH changed management in approximately one-third of patients and resulted in an immediate change in management in a minority of patients. Younger patients are more likely to benefit from early MRI. In older patients suspected of amyloid angiopathy that may preclude future antithrombotic therapy, delayed MRI in the outpatient setting may be reasonable.
Abstract T P324: Prehospital Neurological Deterioration Predicts Intracerebral Hemorrhage
Authors: Gioia Laura C , Zewude Rahel T , Kate Mahesh P , Liss Kim , Rowe Brian H , Butcher Ken
Published: July 2021

Introduction:
Elevated hospital admission blood pressure (BP) has been associated with early neurological deterioration (END) in acute stroke patients. We tested the hypothesis that higher prehospital BP is also associated with END.

Methods:
We conducted a retrospective analysis of a prospectively-maintained centralized database of electronic patient health care reports (ePCR), including serial BP and GCS measurements, of all patients transported by Emergency Transport Services (EMS) to the Emergency Department (ED) of a single hospital during an 18-month period. All patients with an EMS dispatch code for suspected stroke were included. Hospital charts and neuroimaging were utilized to determine final diagnosis of ischemic stroke (IS), intracerebral hemorrhage (ICH), and early death (prior to discharge). END was defined as ≥2 point drop in Glasgow Coma Scale (GCS) score prior to hospital arrival.

Results:
A total of 877 patients were transported by EMS to the ED with suspected stroke. Of these, 420 patients had a final diagnosis of acute stroke (360 IS, 60 ICH). Mean ± SD prehospital SBP was higher in ICH (172 ± 32 mmHg) than IS patients (155 ± 27 mmHg, p<0.001). Initial median (IQR) GCS was lower in ICH (13(5)) than IS patients (15(2), p=0.001). Prehospital END was more common in ICH (9/60 (14.8%) than IS (2/360 (0.6%), p<0.001). Univariate logistic regression indicated that prehospital END predicted the diagnosis of ICH (OR 5.6 (95% CI: 2.6-12.2)). Mean prehospital SBP was similar in patients with (171 ± 39 mmHg) and without END (158 ± 28 mmHg, p=0.29). SBP change during EMS transport was similar in patients with END (-5 (25) mmHg) than those without (-2 (23) mmHg, p=0.88). Prehospital END was more common in those who died (11.8%) than those who survived (0.8%, p=0.001). Mean prehospital SBP was higher in patients who died (166 ± 35 mmHg) than those who survived (157 ± 7 mmHg, p=0.04). Early death occurred more often in ICH (43%) than IS (12.5%, p<0.001).

Conclusion:
Prehospital END is predictive of ICH. Although mean prehospital BP was not higher in patients with END in this retrospective study, it was associated with early death, which is supportive of the hypothesis that elevated prehospital BP may be an acute treatment target.
Abstract T P372: Comparing Methods for Detecting White Matter Abnormalities in Neonates With Hypoxic-Ischemic Encephalopathy
Authors: Ly Monica , Nanavati Tania , Frum Chris , Pergami Paola
Published: July 2021

Purpose:
To compare manual region of interest (ROI) labeling and tract-based spatial statistics (TBSS) by their ability to detect group-wise differences in fractional anisotropy (FA) in the neonatal brain.

Materials and Methods:
Diffusion weighted data were obtained for nine infants with hypoxic-ischemic encephalopathy (HIE) (6 males, 3 females; gestational age range, 36-40 weeks; mean gestational age, 37.8 weeks) and eleven healthy-born infants (10 males, 1 female; gestational age range, 36-40 weeks; mean gestational age, 38.4 weeks) on a 3T scanner. For manual ROI labeling, eight ROIs were drawn freehand for each subject. For TBSS, all FA data underwent an optimized, automated protocol for neonates. Each method was evaluated for detection of decreased FA in HIE infants, sensitivity, specificity, and variability.

Results:
FA values from manual ROI and TBSS were strongly correlated. Both methods found decreased FA in most ROIs for HIE infants. There was no significant interaction between method and group, indicating a similar ability to detect FA differences. Sensitivity (manual: 0.71, TBSS: 0.69), specificity (manual and TBSS: 0.72), and standard error (manual: 0.009, TBSS: 0.007) were comparable.

Conclusions:
Manual ROI labeling and TBSS are comparable methods of diffusion analysis to detect group differences in FA in the neonatal brain
Abstract T P381: Implementing a Rural Stroke Prevention Clinic Using Telemedicine
Authors: Ross Margaret F , Choi Youngbin
Published: July 2021

Introduction:
One in eight strokes is preceded by a transient ischemic attack (Science Daily, 2009). Our primary stroke center serves a five-county area and provides support for stroke care to five rural critical access hospitals. Limited appointment availability and distance to resources were identified as obstacles preventing patients who experienced TIA’s from obtaining essential stroke-prevention work-up. Lack of appointment availability, compounded with the distance to services, resulted in week-long delays before full evaluations could be performed and interventions implemented. Using telemedicine technology, we developed a stroke prevention (TIA) clinic in a rural hospital in Washington State. Referrals for physical therapy, occupational therapy, nutritional counseling, etc. were made to departments of the rural hospital. Follow-up care was conducted in person at the neurologist's office. Patients were seen within one week of symptoms. Patients were also enthusiastic about receiving their care locally and there was a high participation rate (e.g. low no-show rate) for appointments.

Hypothesis:
If stroke prevention assessment services were provided at the local community level, TIA patients identified via the local emergency department would be more likely to attend the medical appointment, obtain needed assessments and receive essential stroke prevention education.

Methods:
The clinic was initially staffed with a neuroscience nurse practitioner who performed patient assessments and presented the patient to the attending neurologist. The neurologist participated remotely via telemedicine. The nurse practitioner and neurologist reviewed pertinent positives and developed a treatment plan in collaboration with the patient. Required testing was performed at the rural facility. Metrics, including revenue generation and patient satisfaction were gathered.

Results:
Patient attendance was excellent and patient satisfaction rated very high. The clinic proved to be a positive revenue generator for the hospital.

Conclusions:
The model has been so successful that we plan to expand the service to our other rural partner hospitals.
Abstract T P68: Outcome of Cervical Internal Carotid Artery Occlusions After Intravenous Thrombolysis in Acute Ischemic Stroke Patients With Tandem Occlusions
Authors: Avellón-Liaño Héctor , Calleja Ana I , Cortijo Elisa , García-Bermejo Pablo , López-Mesonero Luis , Martínez-Velasco Elena , Mulero Patricia , Reyes Javier , Muñoz Pedro L , Arenillas Juan F
Published: July 2021

Background and Objective:
Acute ischemic stroke (AIS) associated with tandem extracranial internal carotid artery (EICA) - middle cerebral artery (MCA) occlusion is burdened with a poor clinical outcome. The recanalization rate of extracranial ICA occlusion after i.v. thrombolysis and its prognostic significance in this group of patients remain largely unknown.

Methods:
Retrospective analysis of a prospectively collected database including consecutive AIS patients treated with i.v. thrombolysis. All patients underwent urgent assessment of extracranial and intracranial large arteries with either computed tomography angiography (CTA) or echo-Doppler ultrasound to document an acute EICA-MCA tandem occlusion prior to thrombolysis. EICA was monitored by control carotid ultrasound and/or CTA in order to detect transition from occlusion to relevant stenosis. Outcome variables: carotid revascularization, in-hospital mortality, Rankin 0-2 at three months, and infarct volume.

Results:
From January 2008 to December 2013, 606 AIS patients received i.v. thrombolysis, of whom 53 (9%) had a documented EICA-MCA tandem occlusion. Four of them died within first 24 hours and EICA could not be monitored. Occluded EICA evolved towards a severe stenosis in 14/49 (29%) after thrombolysis. Angiographic confirmation was obtained in 11 of them, who underwent carotid endarterectomy. EICA recanalization was more frequent among active smokers and was associated with carotid revascularization (79% vs. 0%, p<0.001), lower mortality (0% vs. 26%, p=0.03) and a smaller infarct volume (27 vs. 89 cc, p=0.04).

Conclusion:
Around 30% of AIS patients with tandem EICA-MCA occlusion treated with i.v. thrombolysis experience transition from initially occluded to severely stenosed EICA that can be rescued for revascularization. This evolution is associated with a lower mortality and smaller infarct volume.
Abstract T P74: Mild Stroke in a Telemedicine Network: Identification, Treatment, and Outcomes
Authors: Spokoyny Ilana , Raman Rema , Ernstrom Karin , Meyer Dawn M , Hemmen Thomas M , Demaerschalk Bart M , Meyer Brett C
Published: July 2021

Introduction:
"Mild" stroke is not well defined, but is a relative contraindication for the administration of IV rtPA. Advances in telemedicine have allowed for specialized practitioners to observe the examination, rather than rely on the on-scene examiner. We investigated whether there were differences in rates of identification, treatment, and outcomes of mild stroke patients in the phone compared to the video arms of a telestroke network.

Methods:
The STRokE DOC trials were prospective, randomized, outcome-blinded trials comparing video telemedicine to phone-only evaluations, which assessed eligibility for IV rtPA and correctness of decision-making for 2 hubs and 6 spokes. This analysis included all adult acute ischemic stroke patients from the STRokE DOC trials who were defined as “mild” using a recent definition from the TREAT Task Force. Rates of ICH, mortality, and dichotomized 90-day mRS scores were compared between the video and phone arms.

Results:
Mild stroke accounted for 32% and 29% of the video and phone arms, respectively. The two groups had similar baseline characteristics except hypertension (higher rate in video arm). Of the video mild stroke patients, 13% had poor outcome (mRS>1) compared to 24% of the phone arm (p=0.45). There were no symptomatic ICH or deaths. Among IV rtPA treated mild stroke patients, all of the video arm had good outcome, versus 25% of the phone arm. Of 100 non-treated patients, 34 were excluded because of "too mild" a deficit (TMT). In the phone arm, 7 of these did not meet the TREAT-derived criteria for mild stroke (p=0.03). One TMT patient in the phone arm had poor outcome.

Conclusions:
Mild stroke made up a third of the patients in each group. Some TMT patients in the phone arm did not meet the criteria for mild stroke; their subtle findings may not have been conveyed adequately over the phone. Among IV rtPA treated patients, the phone arm had worse outcomes. The results raise concern regarding accuracy of predicting outcomes for mild stroke patients, especially when based on a phone description. The study numbers were small, so conclusions cannot be definitively made. Future studies are necessary to determine decision making factors within the telemedicine process that influence treatment outcomes among mild stroke patients.