bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP260: Synergistic Inhibitors Halt Brain and Systemic Hemorrhage After Tissue Plasminogen Activator Treatment for Ischemic Stroke
Authors: Zhang Yi , Houng Aiilyan , Reed Guy
Published: March 2022

Tissue plasminogen activator (TPA) treatment for ischemic stroke is complicated by brain hemorrhage and major systemic bleeding for which there is no specific antidote. These bleeding complications reduce the therapeutic value of TPA as well as undermine its therapeutic use in eligible patients. Although the primary causes of TPA-induced hemorrhage are unknown, it may be related to the clot dissolving or fibrinolytic effects of TPA-catalyzed plasminogen activation. We examined whether specific inhibitors of TPA’s fibrin-dependent activation of plasminogen could reduce bleeding after the initiation of TPA therapy for ischemic stroke.

METHODS:
Hybridomas were screened for the production of monoclonal antibodies (MAbs) that inhibited TPA-induced fibrinolysis. After molecular characterization and purification, these MAbs were tested for their ability to stop brain hemorrhage and systemic bleeding triggered by TPA therapy for ischemic stroke.

RESULTS:
Two MAbs were selected that bound with high affinity (sub-nanomolar dissociation constants) to different epitopes on the TPA molecule. These MAbs preferentially inhibited TPA’s fibrin-dependent plasminogen activation but not other catalytic functions; they did not affect plasminogen activation by other agents. When added to human clots, these MAbs synergistically blocked TPA fibrinolysis with greater specificity and potency than a stabilized form of plasminogen activator inhibitor 1. When administered after the onset of TPA therapy for ischemic stroke, these MAbs significantly reduced brain hemorrhage (p<0.05) but did not worsen infarction. The MAbs also markedly diminished TPA-triggered tail bleeding and hemoglobin loss in anesthetized mice.

CONCLUSION:
TPA-induced brain and systemic bleeding in vivo is blocked by potent synergistic inhibitors of TPA’s fibrin-dependent plasminogen activation. This implies that hemorrhage is related to TPA’s fibrin-dependent mechanism of plasminogen activation and that targeted inhibitors of this process may serve as specific antidotes for TPA-associated hemorrhage.
Abstract TP267: Metabolomics Identifies a Branched Chain Amino Acid Profile in Acute Ischemic Stroke
Authors: Kimberly W. Taylor , Wang Yu , Pham Ly , Furie Karen L , Gerszten Robert E
Published: March 2022

Background:
There is limited information about changes in metabolism during acute ischemic stroke. The identification of circulating plasma metabolites modulated during cerebral infarction may provide insight into pathogenesis and identify novel biomarkers.

Methods:
We performed filament occlusion of the middle cerebral artery of Wistar rats compared to sham controls, collecting plasma and CSF two hours after onset of ischemia. Plasma samples from human acute stroke and TIA control subjects were also collected an average of 6 hours after stroke onset. All samples were analyzed using liquid chromatography followed by tandem mass spectrometry. Positively charged metabolites including amino acids, nucleotides and neurotransmitters were quantified using electrospray ionization followed by scheduled multiple reaction monitoring.

Results:
Several metabolites were altered in the setting of cerebral ischemia. We detected a 42% rise in glucose (P=0.006) in stroke subjects compared to TIA controls, consistent with prior observations. We confirmed the validity of the method by comparing glucose measured in our metabolomics platform to bedside glucometer measurements, and we found a correlation coefficient of 0.72 (P<0.0001). We also detected a consistent reduction in branched chain amino acids (BCAAs; valine, leucine, isoleucine) in rat plasma, rat CSF and human plasma compared to the respective controls. We detected a 17% decrease in the level of the branched chain amino acids (P<0.00005). In the human stroke cohort, lower BCAA level correlated with poor neurological outcome (mRS 3-6; Spearman correlation = -0.39, P=0.001).

Conclusions:
Our data support a role for BCAAs in ischemic stroke, which correlates with worse neurological outcome. Intriguingly, BCAAs serve an integral role in the glutamate/glutamine cycle between astrocytes and neurons, and are also a principal signal for energy homeostasis. The extent to which BCAAs are in a causal pathway or are an epi-phenomenon of ischemic stroke remains to be determined.
Abstract TP282: Clinical Predictors To Identify Paroxysmal Atrial Fibrillation After Ischemic Stroke
Authors: Gröschel Klaus , Wohlfahrt Janin , Weber-Krüger Mark , Wasser Katrin , Stahrenberg Raoul , Wachter Rolf
Published: March 2022

Introduction:
Detection of paroxysmal atrial fibrillation (PAF) after an ischemic cerebrovascular event is of imminent interest, because oral anticoagulation as a highly effective secondary preventive treatment is available. Whereas permanent atrial fibrillation (AF) can be detected during routine electrocardiogram (ECG), longer detection duration will detect more PAF but might be resource consuming.

Methods:
Patients with acute ischemic stroke were prospectively investigated with an intensified algorithm to detect PAF (7 day Holter ECG, follow-up investigations after 90 days and one year, ISRCTN 46104198).

Results:
281 patients were prospectively included in the study, 44 of which had to be excluded since they presented with permanent AF as diagnosed by ECG during admission and another 13 patients due other causes leaving 224 patients (mean age: 68.5 years, 58.5% male) as the final study population. 29 (12.9%) patients could be identified to have PAF during prolonged (median: 6.7 days IQR: 4.4-7.0) Holter monitoring, an additional 8 (3.6%) and 5 (2.2%) patients after follow-up investigations after 90 days and 1 year, respectively. In 182 patients no AF could be detected. Multivariate analysis identified advanced age (Odds ratio (OR) 1.04, 95% confidence interval (CI): 1.01-1.08), a higher initial NIH-SS (OR 1.10, 95% CI: 1.00-1.21) as well as clinical symptoms >24h (OR 3.45, 95% CI: 1.06-11.19) and a history of coronary artery disease (OR 2.74, 95% CI: 1.16-6.50) to be predictive for the detection of PAF. Receiver operation characteristics demonstrated an area under the curve of 0.783 for this model. Neither the results of blood analysis, duplex sonography, cerebral imaging nor routine echocardiography could be found to be independently associated with the detection of PAF.

Conclusion:
In acute stroke patients with advanced age, history of coronary artery disease, higher NIH-SS scores and ischemic stroke as the presenting event, a prolonged Holter ECG monitoring and follow-up is warranted to identify PAF. This could increase the detection rate of patients requiring anticoagulation and would be expected to reduce the risk of recurrent stroke in case of consequent anticoagulation of these patients.
Abstract TP29: Endovascular Treatment for Intracranial Arterial Stenosis
Authors: Tsukahara Tetsuya , Hatano Taketo
Published: March 2022

Background and Purpose:
The stenosis of the major intracranial arteries is a major cause of cerebral stroke. We report our experience of endovascular treatment (percutaneous transluminal angioplasty and stenting ; PTAS) for symptomatic stenosis of major intracranial arteries.

Material and methods:
Totally 134 cases of symptomatic intracranial arterial stenosis were treated by PTAS at Kyoto Medical Center from 1998. Indication of PTAS was 1)symptomatic stenosis, which was not successfully treated by medication , and 2)more than 60% stenotic lesion shorter than 15mm in length. Balloon angioplasty (BA) was performed first. Stenting was, then, performed in cases of 1) unsuccessful dilatation or arterial dissection after BA and 2)restenosis after BA.

Results:
Successful dilatation by BA was obtained in 21/26 internal carotid artery (ICA) lesions, in 5/6 middle cerebral artery (MCA) lesions and in 24/29 vertebral artery (VA) lesions (50/61; 82%). Restenosis occurred in 7/26 ICA lesions, 4/6 MCA lesions and 8/29 VA lesions (totally 19/61 lesions; 31%). Successful dilatation by stenting was obtained in 59/60 ICA lesions, 1/1 MCA lesion and 13/15 VA lesions (totally 73/76 lesions; 96%). Restenosis occurred in 5/60 ICA lesions, 1/1 MCA lesion and 1/15 VA lesions (totally 7/76; 9%). Symptomatic complications induced by PTAS occurred in two cases; cerebral stroke and intra cerebral hemorrhage. Stroke recurrence rate after PTAS was 1.1% /year of intracranial ICA lesion and 0.25 % /year of intracranial VA lesion.

Conclusions:
1)Symptomatic intracranial arterial stenosis can be treated by PTAS with a low rate of stroke recurrence and complications. 2)Prevention of restenosis after PTAS is a problem to be solved. 3) Therapeutic merit of PTAS for intracranial lesion needs to be examined comparing to the recent aggressive medical therapy.
Abstract TP293: Antithrombotic Therapy Does Not Increase Cerebral Microbleeding.
Authors: Imamura Junichi , Muta Daisuke , Ishigami Takashi , Hamasaki Tadashi , Nakashima Takahiro , Wakita Masayuki , Hamada Rikuzou
Published: March 2022

BACKGROUND:
Antithrombotic drug users are at risk of intracerebral hemorrhage (ICH). Cerebral microbleeding (MB) is also a risk factor for ICH. Therefore, it is important to clarify the relationship between antithrombotic therapy (AT) and MB in order to prevent ICH. The incidence and number of MBs were evaluated in AT users and nonusers among consecutive acute ICH cases. We attempted to gain insights into the statistical“ black box” of hemorrhagic phenomena in which AT, MB, and ICH are mutually related.

METHODS:
T2*-weighted magnetic resonance imaging (1.5T MRI, 25 brain slices, 2-mm thick) was performed in 273 of 384 consecutive acute ICH (mean age 69.4yrs; M:F, 166:107) to evaluate the incidence and number of MBs, excluding the low-signal intensities associated with the hematoma lesions.

RESULTS:
Of the 273 cases , 86 (32%) cases were users and 187(68%) were nonusers, and MBs were detected in 60 (70%) users and 116 (62%) non-users. The incidence of MBs was comparable between users and nonusers (Chi-square independence test: χ2, 2.018 ; χ2(0.95)3.842; P = 0.155; odds ratio, 0.67129). The mean number of MBs was also not significantly different between users and nonusers [13.03 (median, 7) vs. 12.46 (median 7): t test: t -0.208; t (0.95) 1.653: P = 0.582].

CONCLUSION
AT did not increase MB in this study patients, suggesting that this treatment does not contribute to vascular wall fragility. Complex phenomena leading to ICH were simply categorized into 3 steps: fragility of vascular wall, breakdown of vascular wall, and extension of hemorrhage. Antithrombotic therapy affects only the 3rd step and do not affect the 1st and the 2nd step, whereas hypertension affects all 3 steps. Therefore, in order to prevent hemorrhage extension and severe brain damage, stricter blood pressure control is required in antithrombotic drug users with MBs than in nonusers with MBs.
Abstract TP328: Video Instruction Increases Accuracy in Performance of Nurse Dysphagia Screening
Authors: Reed Charles , Fraley Debra , Sharp Johanna , Hernandez Albert , Proulx Jason , Kattan Ana Carolina , Williams Heather , Wilson Regina L
Published: March 2022

Background and Purpose:
Dysphagia screening prior to oral intake is standard for all stroke patients in assessing for aspiration risk that can lead to pneumonia, intubation, and increased length of stay. The standard teaching method for dysphagia screening consists of nurse to nurse instruction. Inconsistency in teaching methods and content could result in inaccurate screens and negatively affect patient outcomes. We postulated that an instructional video viewable from a smart phone would provide more consistent and easily accessible instruction than the standard teaching method and would improve the accuracy of nurse dysphagia screens.

Methods:
A 3.5 minute teaching video was developed and posted on the internet for on demand viewing. Additionally, within the video, an icon cue was paired with each step in the process for memory triggering and an icon card was distributed. Twenty nurses (n=20) with previous nurse to nurse instruction were video recorded performing a dysphagia screen. They subsequently watched the instructional video via a smart phone and were again video recorded performing a dysphagia screen. Each screening had a maximum score of 10 points based on order and completion of steps and was scored by three independent reviewers. A paired-samples T-test was conducted on the scorings of both educational methods to compare for screening accuracy.

Results:
There was a significant difference in the scores for standard instruction (M=5.6, SD= 2.0) versus video instruction (M=8.4, SD=1.3); t(19)=-8.304,
p
=.000, with a definite improvement in scores after video viewing.

Conclusion:
These results suggest that video instruction has a significant effect on the accuracy of performing dysphagia screens. Participant surveys also revealed that video instruction provided more consistent and concise education as compared to nurse to nurse instruction. We conclude that video instruction is a more effective teaching method than standard nurse to nurse instruction and allows for more consistency in learning and accuracy in application of skills. A larger randomized controlled study is warranted with attention focused on retention of learned information over time.
Abstract TP33: Early DWI Changes in the Thrombolysis Time Window: From DWI-Negative to Malignant Stroke in More than 300 Cases
Authors: Liebeskind David S , Sanossian Nerses , Starkman Sidney , Scalzo Fabien , Alfonso Rodelito , Johnson Mark S , Ali Latisha K , Kim Doojin , Vespa Paul M , Rao Neal M , Yallapragada Anil , Alger Jeffry R , Salamon Noriko , Saver Jeffrey L ,   for the UCLA Stroke Investigators
Published: March 2022

Background:
Thrombolysis for acute stroke is routinely based on time from last known well (TLKW) as the extent of ischemic injury during early epochs is assumed to be minimal. DWI is extremely sensitive, yet rarely acquired prior to thrombolysis and the nature of DWI lesions is largely unknown during this time window. Large or malignant strokes on DWI, however, result in poor outcome after thrombolysis. We retrospectively analyzed a large cohort of DWI acquired as part of a standard MRI protocol for triage of patients at a single center over 8 years.

Methods:
Consecutive patients with discharge diagnosis of ischemic stroke and documented time last known well to DWI MRI acquisition < 4.5 hours were identified. An imaging expert outlined DWI lesions on every axial slice for all MRIs to calculate corresponding lesion volumes as often-subtle changes may evade automated detection. Total DWI volumes were analyzed with respect to age, gender, TLKW and time of day.

Results:
307 stroke patients (mean age 69±17 years, 51% female) from 2004-2012 had DWI with TLKW < 4.5 hours (mean 147±62 min). DWI lesion volume (median 3.67cc) in each case varied extensively (TLKW-DWI < 1 hour (n=8) 0.40cc (0-93cc), 1-2 hours (n=126) 3.02 (0-265), 2-3 hours (n=78) 2.18 (0-103), 3-4.5 hours (n=95) 6.96 (0-227)). Only slight or negligible correlation (r=0.175, p=0.002) was noted between DWI lesion volume and TLKW-DWI time duration. DWI-negative findings < 4.5 hours occurred in 8.5% of stroke cases. Malignant strokes (>70cc) were noted in 7.5%. Older age was associated with DWI-negative strokes (mean 77 vs. 68 years, p=0.013). TLKW-DWI time duration was unrelated to DWI-negative strokes, yet malignant stroke was more common later (p=0.009). Interestingly, the majority of malignant strokes on DWI had TLKW during the daytime.

Conclusions:
DWI changes are extremely variable within 4.5 hours. Most lesions are small, yet malignant strokes are not uncommon. Further work should delineate the clinical determinants of these early malignant strokes to optimize outcomes in acute ischemic stroke.
Abstract TP331: Inpatient Stroke Codes: 2 Step Response Team
Authors: Bergman Deborah L , Alberts Mark J , Bernstein Richard ,   Emergency Response Quality Committee
Published: March 2022

Background and Issues:
Most Primary Stroke Centers have an acute stroke team (AST) to respond to patients experiencing an acute stroke. Data suggests that inpatient stroke code activations for a not true stroke condition can delay the appropriate interventions or treatments, increase the patient’s exposure to radiation, and increase the inefficient use of personnel time and resources. Our goal was to evaluate the inpatient stroke team activation process and develop a procedure/protocol to provide safe and efficient emergent care for the hospitalized patient who might be having a hyper acute cerebrovascular event.

Methods:
We developed a POST STROKE CODE EVALUATION tool to collect timeline data and key issues related to all stroke codes called at our hospital from July 2009 through July 2012. Issues were classified as related to leadership, clinical practice, diagnostic imaging delays, equipment, and clinical support. Issues were reviewed by the monthly Emergency Response Quality Committee. Based on the process improvement reviews a 2 step stroke code activation/response team protocol and procedure was developed and implemented for stroke team activations on hospitalized patients. The 2 step stroke team activation allows the case to be escalated to alert and mobilize additional staff (neuro RN, CT technicians, etc.) and to expedite emergent treatment or procedures for the true stroke cases. Likewise the case can be cancelled if the patient is assessed to have a stroke mimic or needs another care team.

Results:
There were 147 inpatient stroke codes activated from August 3
rd
, 2011 through June 30
th
2012 of which 69 (47%) were escalated to team 2 and 68 (46%) were cancelled for non-stroke conditions or other reasons. In 10 (7%) stroke codes the protocol (escalation to team 2 and/or cancelled) was not followed. True strokes were appreciated in 27 (39%) of the stroke team 2 activations.

Conclusions:
The 2 step stroke code team approach provides the structure for providing safe and efficient care for the hyper acute inpatient experiencing a stroke. Inefficient use of personnel time and resources, unnecessary CT imaging and mobilization of other clinical staff was avoided by almost 50% from implementing this procedure.
Abstract TP346: Hospital System Collaborative has Positive Impact on Door to Needle Times
Authors: Motz Deb , Moore Tracy , Miesen Douglas , Huey Dicky , Freemyer Byron , Grnach Gina , Austin Tommye
Published: March 2022

Background:
Target Stroke is a National quality initiative to increase administration of IV rtPA to within 60 minutes from arrival on at least 50% of eligible ischemic stroke patients. Historically, the National statistic was approximately 25%. The Baptist Health System (BHS) benchmark in January 2010 was at 16.9%. This statistic is for a five hospital system with 1,674 licensed beds and one provider number. BHS has one Stroke Medical Director and follows the same standard of care and stroke order sets at all locations. We will describe the process applied across BHS to decrease door to needle times.

Methods:
One hospital Emergency Department’s (ED) Physician Champion, Director and nursing staff used LEAN methodology to outline present state and streamline the process to eliminate wasted time. Our process already consisted of pre-notification from Emergency Medical Services (EMS) with the estimated time of arrival and a stroke alert page. In our new process, the ED Physician (EDP) and RN1 meet EMS in ambulance bay for a quick assessment. The patient is taken directly to CT scan by RN1 and EMS1. Concurrently, EMS2 reports off to RN2 while assembling the equipment and contacting Specialists On Call (SOC) for the neurology consult. The CT technician notifies the Radiologist of the stroke alert and sends the films to SOC. Upon patient return from CT, the SOC video consultation begins. If a high probability of IV rtPA administration exists per EDP, the rtPA is reconstituted awaiting SOC recommendations. This process was piloted before being duplicated at the other four hospitals.

Results:
BHS achieved Target Stroke Honor Roll status for third quarter 2010 with 71.4% (n = 20/24) of eligible patients treated with door to needle time of 60 minutes or less. Median time was 48.5 minutes. BHS sustained Target Stroke Honor Roll status for July 2010 through June 2011, at 56.6% (n = 56/99) with a median time of 56 minutes.

Conclusion:
BHS was the first hospital in Texas to be awarded the Target Stroke Honor Roll. Incorporating LEAN methodology to eliminate waste, develop guidelines, actions, time durations, and collaboration across the hospital system is an effective means to decrease door to needle time.
Abstract TP347: Improving Performance in Target Time Compliance for Acute Stroke using Structured Feedback to Providers
Authors: Asai Susan M , Robertson Tina , Koenig Matthew A , Nakagawa Kazuma , Chang Cherylee W
Published: March 2022

Introduction:
Time targets for rapid assessment and treatment of acute stroke patients were established in 2005 by the Brain Attack Coalition, including door-to-needle time <60 minutes. At a Primary Stroke Center in Honolulu, HI, we sought to improve compliance with target times by providing structured and meaningful feedback to a multidisciplinary group of acute stroke providers.

Hypothesis:
We hypothesized that delivering direct, structured feedback to providers would improve compliance with target times for rapid evaluation and treatment of acute stroke patients.

Methods:
Utilizing a FOCUS-PDCA framework, a quality assurance project was developed to analyze performance measures and identify barriers to timely administration of IV tPA. Onset-to-door, door-to-stroke-code-activation, door-to-CT-onset, door-to-CT-completion, and door-to-lab-result times were monitored for each IV tPA administration at a single Primary Stroke Center during 2009-2012. Through a series of monthly multidisciplinary stroke team meetings, a simple yet comprehensive reporting tool was developed in 2010, utilizing the “traffic light” concept. This feedback mechanism included a case-by-case analysis of compliance to enhance communication among members of the multidisciplinary stroke team.

Results:
There were 128 stroke code activations with 10 IV tPA administrations in 2009, 147 activations with 21 tPA administrations in 2010, 183 activations with 31 tPA administrations in 2011, and 151 activations with 30 tPA administrations in 2012 year-to-date. During this period, door-to-needle time <60 minutes compliance rates improved from 22.2% in 2009 to 64.7% in 2010 and 53.8% in 2011. In 2012 year-to-date, the compliance rate with the door-to-needle target time has improved to 71.4%.

Conclusion:
The care of the acute stroke patient is a multidisciplinary endeavor. Feedback to providers involved in the stroke code process is an effective way to improve performance. Developing a simple reporting tool proved an efficient, sustainable way to promote awareness and enhance engagement in performance improvement throughout a multidisciplinary system of care.
Abstract TP358: Creation and Utilization of Stroke Teaching Tool Increases Compliance of Stroke Patient Education
Authors: Toporowski Maris
Published: March 2022

INTRODUCTION:
Providing patients with stroke education is vital in secondary stroke risk reduction. A database was utilized which included an education measure that reflected the Joint Commission’s (JC) 5 core components for stroke education. In order to increase consistency with providing stroke patient education, a plan was developed to improve the education process. This plan included development of a carbon print
Patient Health Log
.

PURPOSE:
The purpose of this project was to increase consistency in providing stroke patient education with an emphasis on modifiable stroke risk factors.

METHODS:
A tool titled the
Patient Health Log
was created to include the JC 5 core components of stroke education. Nurses on the stroke unit were educated on rationale for standardization of stroke patient education and the completion of the
Patient Health Log
. Educational processes included: case reviews, discussion and review at staff meetings and daily safety briefings, open forum for clarifying questions, and educational flyers. Auditing of stroke education documentation in the EMR identified a need for improving stroke patient education. Collaboration with the stroke clinical nurse leader allowed for one on one staff education on all shifts. The tool was incorporated into the stroke education packet. The neuroscience nursing staff implemented the
Patient Health Log
in January 2012 for all patients with diagnosis of stroke.

RESULTS:
Stroke patient education and documentation were reflected in a database at 80% compliance prior to implementation of the
Patient Health Log
and intense education processes. In June 2012, six months after implementation of the tool, data analysis supported increased compliance with stroke patient education at 93.9%.

CONCLUSION:
Creation and implementation of a stroke teaching tool, in conjunction with modified nursing stroke education programs, has a positive impact on stroke patient education. The tool’s carbon format provides the patient with an individualized stroke risk reduction action plan to take to all multidisciplinary follow up appointments potentially increasing communication between providers in the outpatient setting.
Abstract TP360: Starting a Stroke Post-Discharge Clinic on a Shoestring Budget
Authors: Westbrook Trish
Published: March 2022

A hospital admission for stroke is a very stressful event and often too short for meaningful education. Stress and emotional levels are high and the stroke itself may result in cognitive challenges. Once at home, much information is forgotten and subtle cognitive and physical dysfunctions may become evident. A follow-up discharge clinic is one possible solution to improving post-discharge care, medication adherence, and lifestyle modification.

While discussing post-discharge challenges at our facility, a nurse practitioner and a speech therapist conceived the idea of a post-discharge stroke clinic. The purpose was to reinforce information taught in the hospital, detect functional disabilities that appeared once home, assure appropriate medical follow-up, and communicate that information to the Primary Care Provider. The clinic was ultimately named “Life After Stroke.”

At “Life After Stroke,” each patient is assessed for physical, occupational, speech, social, financial, and neuropsychological needs. Their logistical and financial ability to obtain follow-up medical care and medications are also evaluated. If financial challenges exist, they are referred to the charitable clinic/pharmacy in their county of residence. Medications are reviewed to assure all secondary prevention measures are addressed and there are no duplications or omissions. The need to continue the medication regimen and follow up care is strongly emphasized. Details of the visit and any referral needs are faxed to the Primary Care Provider at the completion of the visit.

The idea for the clinic was conceived shortly after a new budget year began. Therefore, funds had not been budgeted for the clinic. We had to be very creative to begin a clinic without any financial funding. Forms were developed by the work group, equipment loaned from departments, manpower was donated by some departments, and volunteers filled in the other areas. This has truly been a collaborative and interdisciplinary process with everyone focused on the best patient outcomes. Follow-up has shown an improvement in medication compliance, follow-up care, and patient/family satisfaction.
Abstract TP361: Clinical Integration of Stroke Services to Improve Access to Quality Stroke Care in Waterloo/Wellington Local Health Integration Network
Authors: Tebbutt Tammy , Leonard Patti E
Published: March 2022

Background:
Stroke is the third most common cause of death in the Waterloo Wellington Local Health Integration Network (WWLHIN) area. By 2024, the number of stroke in the WWLHIN will increase 50% as the population grows and ages. The WWLHIN has partnered with the Ontario Stroke Network (OSN) to complete an external review of stroke care in Waterloo Wellington with a goal to enhance local stroke care programming by aligning the present model with the 2010 Canadian Stroke Best Practice Guidelines.

Purpose:
The purpose of the review of stroke care in WWLHIN was to improve access to best practice stroke unit care and provide seamless transitions across the continuum of care and improve patient outcomes.

Methods:
Comprehensive research was completed including, data collection, literature review, and public consultation. In addition, focus groups were conducted to identify key issues and opportunities for improving care. A decision making framework was used to support the siting and sizing of stroke beds in WW LHIN.

Results:
Clinical integration of stroke services across WWLHIN will be implemented to create specialized stroke units with sufficient critical mass that will allow geographically designated units staffed with specialized and dedicated interdisciplinary teams. Stroke services will be consolidated to 3 specialized stroke units for acute and rehabilitative care from 8 sites of generalized medical care. Access to the appropriate level of care will be determined based on standardized, best practice assessment tools and there will no longer be an application process for rehabilitative care. Community Integration Teams are being developed in 4 communities across the WWLHIN to facilitate early supported discharge and seamless transition into the community.

Conclusions:
The newly designed
Quality Stroke System
in WWLHIN will provide every stroke patient with access to best practice stroke unit care and timely access to early intensive therapy. Clinical integration of stroke services and relocation of stroke beds will occur to achieve critical mass. Patients will receive the right care in the right place at the right time.
Abstract TP382: A Bayesian Network for Reasoning on Acute Ischemic Stroke Intervention
Authors: Arnold Corey W , Love Alexa , El-Saden Suzie , Liebeskind David S , Andrada Lewellyn , Saver Jeffery , Bui Alex A
Published: March 2022

INTRODUCTION:
As endovascular treatment options for acute ischemic stroke evolve, it is important to study the conditions and decisions that lead to successful outcomes so that future interventions may be better tailored for each individual. Bayesian networks provide a method for studying the conditional dependencies between variables and have been applied in other areas of medicine. In this work, we present a Bayesian network of acute ischemic stroke for analyzing the dependencies between a patient’s clinical and imaging presentation, therapeutic interventions, and outcomes.

METHODS:
790 unique episodes of acute ischemic stroke from the last five years (2006-2012) were retrieved from our institution’s quality improvement repository. A subset of variables from each case was extracted and modeled in a Bayesian network. Variable selection and connectivity was guided by a review of current practice guidelines and the domain knowledge of clinical investigators. Conditional probabilities between variables were then calculated using expectation maximization.

RESULTS:
The Bayesian network may be manipulated through a graphical user interface to investigate the likelihood of different clinical scenarios. For example, evidence regarding patient presentation may be set and then combinations of interventions may be applied to observe possible outcomes. Additionally, the model accommodates the integration of utility nodes to support exploration of a patient’s projected quality-adjusted life expectancy (QALE) as a function of their clinical state and variable treatment decisions.

CONCLUSION:
The presented model supports a pertinent set of variables and provides an initial tool for clinicians and researchers to study how combinations of patient evidence and interventions affect outcomes in acute stroke. This information may be useful for suggesting subsequent investigations on methods for improving existing treatment protocols.
Abstract TP383: Use of Oral Anticoagulants in FAST-MAG Patients
Authors: Cherin Samantha B , Sanoff Randy , Chatfield Fiona , Sanossian Nerses , Hamilton Scott , Eckstein Marc , Pratt Frank , Stratton Sam , Liebeskind David , Kim Doojin , Restrepo Lucas , Ali Latisha , Valdes-Suerias Miguel , Kim May , Obviagele Bruce , Conwit Robin , Starkman Sidney , Saver Jeffrey ,   for the FAST-MAG Investigators and Coordinators
Published: March 2022

Background:
Many patients being evaluated acutely in the field for acute ischemic stroke will be on anticoagulation, usually for atrial fibrillation. Ischemic stroke related to atrial fibrillation is more severe than that of other etiologies and there is the added risk of intracranial hemorrhage in these patients. We describe rates anticoagulant and clinical characteristics use among stroke patients being evaluated by paramedics <2 hours from symptom onset.

Methods:
The Field Administration Stroke Therapy-Magnesium (FAST-MAG) is a phase 3 NIH-funded, randomized, placebo-control study of prehospital initiated magnesium sulfate within 2 hours of stroke onset. Data on demographics and examination was obtained from paramedic run sheets and medical records.

Results:
Of the 1116 consecutive, mean age was 70 (SD 13) years, 40% were women, 23% Hispanic Ethnicity, 77% white race, and 23% had ICH on initial imaging. A total of 114 (10%) were on anticoagulation at EMS evaluation, most often for known atrial fibrillation (n= 83) and/or valvular heart disease (n=44). Those on anticoagulation were less likely to present with ICH (16% vs 25%). Those on anticoagulation were often found to have an INR less than 2 (n=77 66%), 26 were therapeutic with an INR between 2 and 3, and 11 had an INR > 3. NIH scores were higher at the time of ED arrival (11.16 vs 9.87) and at the 24hour mark (8.70 vs 7.97). Additionally, patients with a sub- therapeutic INR (0-2) had the highest observed NIHSS (mean 12.03). No association between high INR (over 3.0) and intracerebral hemorrhage was seen (p=0.752).

Conclusion:
Patients on anticoagulation therapy most often present with ischemic stroke. A sub therapeutic INR led to greater severity of stroke.
Abstract TP39: Delayed CT "Swirl Sign" Predicts Outcome in Intracerebral Hemorrhage.
Authors: Khurana Dheeraj , Kesav Praveen , Ahuja Chirag , Prabhakar Sudesh
Published: March 2022

BACKGROUND:
“Swirl sign” on an initial CT scan indicates ongoing hemorrhage in a hematoma and has been associated with increased mortality.

OBJECTIVE:
To assess CT swirl sign(CTSS) for predicting outcome in acute primary intracerebral hemorrhage.

METHODS:
Acute ICH patients within 24 hours of symptom onset were recruited. Baseline Non contrast and contrast enhanced CT scan and CT angiography of the brain was done. Follow up CT(FU CT) scan was done 24 hours from baseline.Hematoma volume(HV), CT spot and swirl sign were assessed. All patients were managed as per standard guidelines. Outcome assessment with modified rankin scale(mRS) was carried out at 1 month and 3 months

RESULTS:
25 patients were recruited.Mean age was 52.44+11.35years,72% males, time from symptom onset ranged from 180-990 mins (mean-499 mins), GCS range 7-15 ,NIHSS range 6-33 (Mean 19.76), Mean systolic, diastolic and mean arterial pressures at baseline were 186.40 ,108.72 and 134.32 mm Hg. 10 (40%) had hematoma expansion (HE; > 33% increase in hematoma volume on FU CT). Mortality was 36% (9). Prevalence of CT spot sign was 4% . CTSS at baseline and follow-up was 24% (6)and 32%(8) respectively. 87.5% with delayed CTSS had a poor outcome (mRS>2). Delayed CTSS was associated with increased early mortality (1 month) (p = 0.005) and poor outcome at 3 months (p=0.03).

CONCLUSION:
Delayed CT Swirl sign (>24 hours) is a predictor of mortality and outcomes in acute primary supratentorial intracerebral hemorrhage. It may serve as a marker for aggressive BP lowering even in patients presenting after 6-8 hours
Abstract TP422: Prevalence and Outcome of Post-Admission Global Brain Edema in Patients with Subarachnoid Hemorrhage
Authors: Majidi Shahram , El-Nashar Adel , Tariq Nauman , Qureshi Adnan I
Published: March 2022

Introduction:
Global cerebral edema (GCE) has been recognized in patients with aneurysmal subarachnoid hemorrhage (SAH). The pathophysiology and time course of GCE is not fully understood due to difficulties in quantitating GCE.

Objective:
To quantitate GCE using advanced image analysis software on serial computed tomographic (CT) scans and to determine the temporal evolution in patients with SAH.

Methods:
Thirty two consecutive SAH patients were identified and all the brain CT scans (n=96) which had been performed during the first week of admission were collected. Using Analyze software (AnalyzeDirect, Overland Park, KS), total brain volume was calculated in each CT scan after subtracting ventricular, gyral, and blood volumes. The difference of total brain volume between follow up and baseline CT scans calculated as GCE. The associations between GCE and patients’ demographic and clinical characteristics and hospital outcome were analyzed.

Results:
A total of 12 (38%) of 32 patients had GCE at 24 hour CT scan. The number increased to 14 (44%) and 17 (53%) in 48 hour and one week follow up CT scans, respectively. Mean volume of GCE was 30 ml (95% CI: 0.9-59), 39 ml (95% CI: 24-54), and 33 ml (95% CI: 22-44) in 24 hour, 48 hour, and one week follow up CT scans, respectively. Although the mean age of patients with GCE at 24 hours was higher than patients without edema, the difference was not statistically significant (56 versus 49; p=0.2). Gender, race, Fisher, Hunt and Hess scores, and in-hospital mortality were not different between patients who developed or did not develop GCE. Patients with favorable outcome (modified Rankin Scale<3) had significantly higher volume of GCE in 24 hour follow up CT scan in comparison to patients with poor outcome (mean; 95% CI: 15.6 ml; -15.6-46.8 versus 7.5 ml; 1.7-13.3, p<.0001). The volumes of GCE in 48 hour and one week follow up were also higher in patients with favorable outcomes but the difference was not significant.

Conclusions:
Our study demonstrated that GCE can occur in more than 50% of SAH patient during the first week with the rate of occurrence depending upon the time interval elapsed from admission.
Abstract TP427: Comparison of Clinical Characteristics of Neurogenic Stunned Myocardium in Patients with Subarachnoid Hemorrhage and Acute Ischemic Stroke
Authors: Murthy Santosh B , Shah Shreyansh , Hannawi Yousef , Georgiadis Alexandros , Smirnakis Stelios , Bershad Eric , Suarez Jose , Venkatasubba Rao Chethan
Published: March 2022

Aim:
Neurogenic stunned myocardium (NSM) after subarachnoid hemorrhage (SAH) is well known, but there is paucity of data regarding its occurrence following acute ischemic stroke. The aim of this study is to contrast the characteristics of NSM in SAH and acute stroke.

Methods:
An electronic literature search was performed with Medline and Google Scholar, for English-language articles using the terms “subarachnoid hemorrhage” along with “stunned myocardium” or “Takotsubo cardiomyopathy”. The search revealed 35 articles, from which 10 studies were selected based on the following criteria: prospective studies, non-traumatic SAH, N >25 patients and documentation of regional wall motion abnormalities (RWMA). For studies from the same institutional database, the one with most comprehensive documentation of cardiac parameters was selected. Another search was conducted using the terms “acute ischemic stroke” along with “stunned myocardium” or “Takotsubo cardiomyopathy” resulted in only 7 case reports/series.

Results:
In this descriptive study, 98 out of 504 SAH patients had NSM, evidenced by RWMA (23%). The mean age was 54.8 years and 68% of patients were females, mean Hunt Hess grade was 2.5 and mean LVEF was 55.8%. The mean troponin level was 1.24. The most commonly involved segments were mid-ventricular, basal and apical, in that order. A significant improvement in LVEF occurred in 70.4% of patients. Among stroke patients, the mean age for NSM was 72.5 years and 77% were females. Insular cortex was involved in 46% of cases. Mean troponin elevation was 0.64 and mean LVEF was 34.4%. Regarding outcomes, 84.6% of patients had significant improvement in LVEF, with full recovery in 53.8%.

Conclusion:
NSM was more common in females, with favorable prognosis. Mid-ventricular segment was most commonly involved in SAH. The mean troponin was twice higher in SAH, raising the possibility that sympathetic overdrive is stronger in these patients. Only half the patients with NSM following stroke had insular involvement, implying other structures may be involved in the neuro-cardiac axis. Lack of prospective studies in stroke patients, and reports only describing Takotsubo cardiomyopathy, which selectively involves apical segments, are limiting factors.
Abstract TP47: Infarct Growth Does Not Predict Functional Outcome For Small Vessel Stroke
Authors: De Silva Deidre A , Omar Eunizar , Manzano Jennifer J , Christensen Soren , Wong Meng Cheong , Chang Hui Meng , Wardlaw Joanna M , Bath Philip M , Chen Christopher P
Published: March 2022

Introduction:
Infarct growth has been shown to be a predictor of clinical outcome following ischemic stroke and has been used as a surrogate in reperfusion studies. There are no data whether the association of infarct growth and clinical outcome depends on stroke etiology. Furthermore, there is uncertainty on how to handle small volume infarcts with some studies excluding them from analyses. We studied the relationship between infarct growth and functional outcome in stroke patients with small volume infarcts for subgroups with small and non-small vessel etiologies.

Methods:
We studied 37 patients in the MRI substudy of the Efficacy of Nitric Oxide in Stroke (ENOS) trial with baseline infarct volumes of ≤5ml. None of the patients were treated with reperfusion strategies. Brain MRI was performed serially at baseline within 48 hours of onset, on days 7 and 90. Infarct growth was measured as the volume difference between final T2 and baseline DWI lesions. Good functional outcome was defined as day 90 modified Rankin score ≤2 and poor as >2.

Results:
Among the 26 patients with underlying small vessel etiology, there was no difference between those with good and poor outcomes in terms of absolute [median 0.0 (IQR -0.4 to 1.1) vs 0.1 (-0.7 to 0.2) mL, p=0.802] and relative infarct growth [median -3 (-27 to 81) vs 8 (-46 to 10) %, p=0.802]. However, in the 11 patients with etiologies other than small vessel disease, patients with good outcome had less absolute [median -0.9 (-1.6 to 0.7) vs 3.2 (0.2 to 9.1) mL, p=0.033] and relative infarct growth [median -59 (-81 to 9) vs 154 (35 to 292) %, p=0.019] compared to those with poor outcome.

Discussion:
In small volume strokes, infarct growth was not associated with functional outcome for small vessel stroke although there was a significant association for other stroke etiologies. This novel finding in this small sample should be confirmed in larger studies. Our findings are expected as small vessel stroke involves occlusion of penetrating arterioles which supply small, limited yet strategically important brain regions. Thus, while infarct growth may be a suitable surrogate for clinical outcomes for small volume infarcts due to non-small vessel disease, but it may not be for small vessel strokes.
Abstract TP48: Caveats When Using the CT Perfusion Derived Cerebral Blood Volume Lesion to Help Guide Thrombolysis Treatment in Acute Ischemic Stroke
Authors: d’Esterre Christopher D , Fainardi Enrico , Lee Ting Yim
Published: March 2022

Background:
Very low CT perfusion (CTP)-derived cerebral blood volume (CBV) has shown promise in defining infarction and may also be used as a predictor of hemorrhagic transformation (HT). We sought to determine whether the CTP-CBV defect (CBVD) correlates with final infarct volume, as defined by a 3 month NCCT, and whether the CBV defect volume is associated with hemorrhagic transformation (HT).

Methods:
CBV defect (CBVD) volumes were outlined on all CBV functional maps using previously established CBV thresholds for infarction, CBV<1.1 ml•100g-1 and CBV<0.75 ml•100g-1 for gray and white matter, respectively. Final infarct volumes were traced on 3 month NCCT. Patients were separated into two sub-groups according to the percent truncation of the ischemic tissue TDC (ITDC) calculated at onset. A model of linear regression was used to observe whether the admission CBVD could predict final infarct volume on NCCTD. Average admission CBVD volumes for patients with hemorrhagic infarction (HI), parenchymal hematoma (PH) and no HT were calculated and compared.

Results:
Thirty patients were included. There were 21/30 patients (70%) whose onset CBVD volume was less than the NCCTD at 3 months; mean volume difference was 24.2 [range(1.5 to 88mL)]. Six of these patients had truncation of the ITDC at onset. There were 9 patients (30%) whose onset CBVD volume was larger than the final infarct volume from the 3 month NCCT (NCCTD); mean volume difference was -9.9mL [range(-28.5 to -0.2mL)]. Of these 9/30 patients, 8 had truncation of the ITDC at admission. For the onset CBVD versus NCCTD, the coefficients of determination (R2) were 0.56, 0.70 and 0.46 for all patients, truncation positive and truncation negative groups, respectively. 30% of patients had hyperemia at onset, defined as an increase in CBV relative to the contralateral side. HT was observed in 13/30 patients: 8 HI, 5 PH. Symptomatic intracerebral hemorrhage was found in 1 patient. Average CBVD volumes for HI, PH and non-HT groups were 15.7±17.4, 47.1±29.9 and 16.3±27.0, respectively (p > 0.05).

Conclusions:
The acute CBV defect remains an important diagnostic parameter for acute ischemic stroke if both truncation of the ITDC and variable perfusion states within tissue destined to infarct are taken into account.
Abstract TP52: Bedside Monitoring Of Resting State Functional Connectivity Networks In Acute Ischemic Stroke Patients Using Diffuse Optical Tomography
Authors: KUMAR GYANENDRA , EGGEBRECHT ADAM T , CULVER JOSEPH P , LEE JIN-MOO
Published: March 2022

Background:
Recent studies have shown that functional connectivity (FC), an MR method that maps synchronized neural activity throughout the brain during rest, is profoundly altered after stroke and may predict outcome better than structural imaging. However, logistic and care constraints limit its use in acutely ill stroke patients. Here, we evaluate a novel portable and inexpensive neuroimaging modality, Diffuse Optical Tomography (DOT), capable of monitoring FC at the bedside in a cohort of acute ischemic stroke patients.

Methods:
Brain activity was measured with DOT using a flexible imaging cap that covers much of the frontal, temporal, parietal, and occipital lobes. Resting state brain activity was measured in 7 patients (6 females; mean age 66 years; median NIHSS14, range 3-20; tpa=2) as well as 5 healthy controls. Seed-based maps of FC were generated by calculating the correlation of the time trace of each voxel with the time trace of a given seed.

Results:
Data from a healthy subject and two stroke cases are shown below. The seed-based FC map for the healthy subject displays typical bilaterally symmetric correlation relative to the seed (black circle). Stroke subject 1 shows a moderate lesion and some disruption in the fc map. Stroke subject 2 displays a large infarct and profound disruption of the FC map. The level of disruption of FC of resting state networks is shown to be correlated with the severity of the stroke.

Conclusion:
This study demonstrates the feasibility of utilizing DOT at the bedside to monitor resting state networks in patients during acute ischemic stroke.