bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP497: And the Golden Lobe Award for Best Stroke Patient Outcomes Goes To
Authors: Schoech Ashley , Whisler Kacey , Poston Lindsey , Linyard Paola , Rodriguez Brandi , Holland Donna L
Published: January 2019

Background and Purpose:
This process improvement project was conducted to improve the emergency department (ED) door to needle time (DTN) for intravenous (IV) alteplase times for stroke patients arriving both by local emergency medical services (EMS) and by private owned vehicles (POV). Ultimate goal was to meet American Heart Association (AHA) and American Stroke Association (ASA) Get With the Guidelines (GWTG) Target Stroke Honor Roll Elite Plus.

Methods:
A two-year nurse led multidisciplinary collaborative process improvement (PI) plan was designed to include local EMS, emergency department (ED) and radiology personnel. The patient workflow was streamlined allowing EMS Stroke Alert patients, as well as patients arriving in the ED in POV, with stroke symptoms, to go straight to the radiology department for immediate computed tomography (CT) scans. The PI plan was based on Six Sigma methodology and included a 90-day pilot data analysis led by Registered Nurse (RN) Directors, Neurologists, ED Physicians, Medical Imaging, Quality Improvement, and RN Stroke Coordinator. As part of the project design a recognition award was given to team mates with the best patient outcomes. The “Golden Lobe” award was awarded to EMS and ED team members for their significant improvement in stroke patient outcomes.

Results:
January 2016 to July 2018, a total of 79 were included. Average DTN times for EMS patients decreased 5.4 minutes, from 40.7 to 35.3. Average DTN times for POV patients decreased 17.8 minutes, from 51.8 to 34. Additional improvements were noted on transferring large vessel occlusion, drip and ship cases 81 minutes faster, from 196 to 115. Complication rates associated with IV alteplase decreased by 2.9% and stroke mimic rate reduced by 6.1%.

Conclusion:
In conclusion, nurse led multi-disciplinary collaborative PI project was successful in reducing DTN time for patients exhibiting stroke symptoms regardless if they arrived EMS or POV. Not only did the ED team improve DTN time, they also decreased IV alteplase complication rates, stroke mimic rates and stroke interventional transfer times.
Abstract WP502: Standardized Code Stroke Inpatient Activation Process Resulted in Consistent Acute Stroke Evaluation Times Regardless of Primary Problem or Patient Location
Authors: Cox Kailey , Lesko Alyx , Lucas Lindsay , Sheets Brandan , Chandler Ronda , Baraban Elizabeth , Clark Diane
Published: January 2019

Introduction:
Inpatient strokes have a higher mortality risk and longer length of stay compared to community-onset strokes. The inpatient stroke population is often not included in national registries. This study examines a hospital-wide standardized process for acute triage of Code Stroke Inpatient Activations (CSIAs) at a Comprehensive Stroke Center.

Methods:
CSIA data collected between September 2016-July 2018 from the Stroke and Rapid Response Team pager were used. False CSIAs were excluded. Outcomes included percentage of CSIAs by patient location (PL), primary problem (PP), and final discharge diagnosis (FDD), as well as percentage treated with IV-alteplase (tPA) and thrombectomy. Evaluation times of symptom discovery-to-stroke MD page (Sx-SMDP), symptom discovery-to-CT (Sx-CT), stroke MD page time-to-CT (SMDP-CT) were compared across PP and PL using one-way analysis of variance for log-transformed time with pairwise comparisons. Among CSIAs with a new stroke diagnosis at discharge, the percentage found in our Comprehensive Stroke Registry (CSR) was identified.

Results:
Among all CSIAs (n=99), 47.1% (n=41) of patients were admitted for cardiac, post cardiac surgery or TAVR; 19.5% (n=17) for stroke; and 33.3% (n=29) for other PP. Among 79 CSIAs with PL, 30.4% (n=24) were in cardiac units, 24.1% (n=19) in stroke units, 21.5% (n=17) in non-stroke/non-cardiac units, 17.7% (n=14) in peri-procedural units, and 6.3% (n=5) in the observation unit. Among 72 CSIAs with FDD, 72.2% (n=52) had a new stroke diagnosis whereas 27.8% (n=20) did not. Overall treatment rate was 6.0% with median Sx-tPA of 68 minutes (n=2) and median Sx-GP of 147 minutes (n=4). No differences in Sx-SMDP, Sx-CT, or SMDP-CT by PL or PP were found. Among 52 CSIAs with stroke FDD, 21.2% (n=11) were identified as inpatient strokes at discharge in our CSR.

Conclusions:
Standardized Code Stroke Inpatient Activation process resulted in consistent evaluation times regardless of primary problem or patient location. Code Stroke Inpatient Activations in the cardiac population need further examination and may reflect the presence of comprehensive cardiac surgical services at this hospital. National stroke registries do not reflect the size or full spectrum of the inpatient stroke population.
Abstract WP504: Utilizing a Nurse Driven Hand off Tool to Improve Neuro Interventional Post Procedural Documentation
Authors: Wesling Judith R , Clements Annette
Published: January 2019

Introduction:
In preparation for Comprehensive Stroke Certification (CSC) survey, auditing of pre-, intra-, and post-procedural documentation of neuro-interventional (NIR) angiograms was performed. Auditing identified post-procedural documentation was not consistent with physician orders or clinical practice guidelines (CPG) designated by the Joint Commission. Nursing developed a post-procedure tool to improve nurse to nurse hand-off and documentation compliance.

Methods:
A post-procedure tool was developed for nurse hand-off when transferring patients from NIR to Critical Care. The one-page tool contained the type of procedure performed, post procedure orders, time of sheath removal, type of required documentation (vital signs, neurological and neurovascular exams), and time-frame grid when documentation was due. Also included was criteria for issues requiring physician notification and management of groin hematoma flow chart.

Results:
Initial audits revealed virtually no post assessments were documented 100% correctly per order. After implementation and during time of CSC survey, auditing revealed an improvement to only 31%, but demonstrated a significant improvement from having substantial assessments missing to only 1-2 items. The CSC designation was granted with a requirement for improvement (RFI) to improve documentation. Additional focused auditing identified at-risk time frames, and specific assessments and staff locations to target further education. Editing of the tool was made with suggestions from nursing. Jan-Jun 2017 auditing demonstrated >80% compliance in all three assessment requirements with June having 91% neuro assessments documented, and 100% with neurovascular and vital signs documented appropriately for the required six hours of focused assessments. Nurses feel the tool has improved communication and provides a better hand-off between NIR and Critical Care.

Conclusions:
Compliance with orders and CPG required documentation, as well as improved nurse to nurse hand-off can be achieved utilizing a comprehensive tool identifying the type of assessment and designated time assessments are required.
Abstract WP505: Post tPA Neuro Vital Signs, a New Approach With the Help of an Old Friend, Part 2
Authors: Lee Jason , Broadway Mary K , Jeansonne Stephanie W
Published: January 2019

Background:
Post tissue plasminogen activator (tPA) physiological and neurological vital sign checks are an important and required part of stroke patient care. Physiological monitoring is aided by modern technology and the ability to automate the transfer of data to patient records and alert nurses of detrimental changes. The neurological checks are still a manual entry and performance of the task by nurses that must be performed very frequently and can take several minutes to complete properly. Many systems have defaulted to the use of the NIHSS for these checks. Continued study into the dependability of the Houston Methodist Stroke Change Score(HMSCS) as a replacement tool for the full NIHSS in the post tPA monitoring period

Method:
Using parts of the NIHSS, selected items were used to show neurological changes, have lower variability and decrease the time required to evaluate yet maintain patient safety. With IRB approval, a retrospective study of all patients that received tPA at Houston Methodist Hospital Medical Center and had NIHSS scores entered into the EPIC system. The NIHSS was collected for the baseline through the 24 hour post tPA administration time only. Cases that had a 2 point increase or more were evaluated for neurological imaging due to a change in patient condition. These NIHSS changes were compared to our HMSCS tool.

Results:
86 patients met the criteria for inclusion from January 1
st
, 2017 through October 9
th
, 2017. 16 cases met criteria for comparison of scales. 100% correlation between NIHSS and the HMSCS for a 2 point change or more for all cases found that had significant neurological change. 5 cases of hemorrhagic transformation were included and had a 100% correlation.

Conclusions:
This was found to be a second positive result for our study. Use of the HMSCS is being introduced to our facility in place of the NIHSS for post tPA monitoring. The NIHSS was timed and took over 8 minutes on average for a nurse to complete fully. The HMSCS was timed and took less than 3 minutes on average to complete fully. We have estimated that average nurse would gain 5 min per exam at each of the 36 time points without compromising patient safety or quality.
Abstract WP515: Depression is Associated With Persistent Smoking After Stroke and Myocardial Infarction
Authors: Parikh Neal S , Salehi Omran Setareh , Elkind Mitchell S , Willey Joshua
Published: January 2019

Introduction:
Depression is associated with poor risk factor control after stroke and myocardial infarction (MI). We sought to estimate the prevalence of objectively-measured persistent smoking in stroke and MI survivors in a nationally representative sample, and we hypothesized that depression is associated with persistent smoking.

Methods:
We performed a cross-sectional analysis using data from 5 cycles of the National Health and Nutrition Examination Survey (2005-2014). Participants in each independent cycle were asked detailed questions about their medical history and underwent neuropsychiatric and laboratory assessment. We included participants 20 years and older who reported a prior stroke or MI and regular tobacco smoking at the time of the event. Individuals who reported both stroke and MI were categorized based on the more recent event. Depression, at the time of survey participation, was defined using a validated threshold (
>
10) on the Patient Health Questionnaire-9 scale. Persistent smoking was defined using validated serum cotinine measures that minimize the effect of second-hand smoke exposure. Multivariable logistic regression methods for survey data were used to assess the association between depression and persistent smoking while adjusting for demographics and smoking-related conditions and behaviors.

Results:
We identified 1,215 participants with prior stroke or MI who also reported regular tobacco smoking at the time of the event. The mean age was 74.1 years (standard error [SE], 0.5), and the mean duration since the event was 9.7 years (SE, 0.4). Serum cotinine levels revealed evidence of persistent smoking in 429 (41.8%; SE, 1.9%) individuals. Depression was present at the time of survey participation in 30% of persistent smokers versus 13% of former smokers (P<0.0001). In unadjusted analysis, depression was associated with persistent smoking (OR, 3.1; 95% CI, 1.9-4.8). In fully adjusted models, the association was attenuated (OR, 2.01; 95% CI, 0.99-4.09).

Conclusions:
In this nationally representative sample, 42% of smokers with stroke or MI had laboratory evidence of persistent smoking several years later. Improved smoking cessation efforts and interventions are needed, especially for those with depression.
Abstract WP517: Influence of Smoking on CYP2C19 Genetic Variants and Clopidogrel Efficacy in Patients with Minor Stroke or TIA
Authors: Wang Tingting , Pan Yuesong , Lin Jinxi , Anand Raja , Johnston S. Claiborne , Wang Yongjun , Wang Yilong
Published: January 2019

Background and Purpose:
Whether smoking has an effect on the association between CYP2C19 genetic variants and clopidogrel efficacy is not clear. This study was aimed to estimate the influence of smoking on the association between CYP2C19 genetic variants and clopidogrel efficacy among patients with minor stroke and TIA.

Methods:
In total of 2961 patients from the CHANCE trial were involved in this substudy and successfully genotyped for both two single-nucleotide polymorphisms of CYP2C19 (*2 and *3). Current smokers were defined as those who smoked at least five cigarettes per day in the last month. The primary clinical efficacy outcome of this study was a new stroke. Cox proportional risk regression model was used to evaluate the interactions between CYP2C19 loss-of-function allele (*2 and *3) carrier status and clopidogrel efficacy stratified by smoking status.

Results:
There were marginal significant interactions between CYP2C19 loss-of-function carrier status and antiplatelet treatment regimen for the risk of recurrent stroke and composite events (p = 0.054, p = 0.051, respectively) among smokers, but not in non-smokers. Among smokers, clopidogrel plus aspirin decreased the recurrence rate of stroke compared with aspirin alone in noncarriers (3.8% vs 11.8%, hazard ratio [HR], 0.32; 95% confidence interval [CI], 0.15-0.65, p = 0.002), but not in carriers (8.1% vs 10.8%, HR, 0.73; 95% CI, 0.46-1.17, p = 0.19). Similar results were also found for the recurrence rate of composite events in smokers. No significant difference was found for hemorrhage events in all groups.

Conclusions:
Among patients with minor stroke or TIA, marginal significant interactions were found between CYP2C19 loss-of-function carrier status and clopidogrel efficacy in smokers, but not in non-smokers. It seemed that among smokers, clopidogrel plus aspirin might decrease the recurrence rate of stroke in noncarriers of CYP2C19 loss-of-function allele compared with aspirin alone.
Abstract WP52: There is No Association Between the Number of Stent Retriever Passes & the Incidence of Hemorrhagic Transformation for Patients Undergoing Mechanical Thrombectomy
Authors: Hassan Ameer E , Kotta Hari , Shariff Umar , Preston Laurie , Tekle Wondwossen G , Qureshi Adnan I
Published: January 2019

Background:
Previous research has primarily investigated the association between hemorrhagic transformation (HT) incidence and baseline variables (i.e. pre-procedural variables) rather than the association between HT incidence and endovascular treatment (EVT) procedural variables (e.g. the number of passes with a stent retriever). Current stent retriever guidelines recommend a maximum of 2 passes per device and not more than 3 passes per vessel.

Objective:
To assess the association, if any, that exists between the number of passes with a stent retriever and the incidence of HT for patients undergoing mechanical thrombectomy.

Materials and Methods:
Data from patients who underwent EVT with a Trevo, Solitaire, or Penumbra stent retriever from the years 2012 to 2018 was collected and categorized according to the incidence of HT. HT was defined as any intracranial hemorrhage in the territory of the initial ischemic event within admission and determined via CT scan read by radiology. Univariate and bivariate statistical analyses were conducted on the number of passes per procedure with a stent retriever, patient demographic data, patient morbidities, and patient outcomes to investigate their association with HT incidence.

Results:
Of 329 total patients, 46 (14%) had HT. The HT group had an average[SD] of 1.65[0.67] and range of [1-3] passes while the non-HT group had an average[SD] of 1.63[0.86] and range of [1-5] passes per procedure. Admission NIHSS score (p = 0.0003) and the incidence of diabetes mellitus (DM) (p=0.05) were significantly higher in the HT group. Upon bivariate logistic regression, the number of passes failed to show any association with HT (p = 0.804) while admission NIHSS score was found to have an OR of 1.07 (95% CI: 1.03 - 1.12, p = 0.001) with HT incidence.

Conclusion:
No significant association was found between HT incidence and the number of passes with a stent retriever. Further research investigating additional EVT procedural variables is warranted.
Abstract WP529: Anticoagulation Therapy Reduces Recurrent Stroke in Embolic Stroke of Undetermined Source (ESUS) Patients With Elevated Markers of Coagulation and Hemostatic Activation
Authors: Hassani Sara , Sharashidze Vera , Rangaraju Srikant , Rathakrishnan Priyadharshi , Ellis Deandrea , Duncan Alexander , Hoskins Michael , Marmarchi Fahad , Belagaje Samir , Bianchi Nicolas , Belair Trina , Henriquez Laura , Monah Kaslyn , Nahab Fadi
Published: January 2019

Introduction:
Markers of coagulation and hemostatic activation (MOCHA) have previously been shown to identify ESUS patients who are more likely to have subsequent diagnosis of atrial fibrillation (AF), malignancy, venous thromboembolism (VTE) or other defined hypercoagulable disorders. The objective of this study was to evaluate whether anticoagulation therapy reduces recurrent stroke in ESUS patients with an abnormal MOCHA profile.

Methods:
Consecutive ESUS patients seen in the Emory Clinic from January 1, 2017 to June 30, 2018 underwent outpatient cardiac monitoring and the MOCHA profile including serum d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex and fibrin monomer obtained ≥ 2 weeks after the index stroke. All patients were on antiplatelet therapy at the time of MOCHA testing and an abnormal MOCHA profile was defined as ≥ 2 elevated markers. Anticoagulation was offered to patients with an abnormal MOCHA and patients were evaluated for recurrent stroke or hemorrhage at routine clinical follow-up. We compared this patient cohort (cohort 2) to a historical cohort (cohort 1) who underwent the same protocol but remained on antiplatelet therapy during follow-up.

Results:
Baseline characteristics were similar between cohorts except that cohort 2 was less likely to have diabetes (43% vs 23%, p=0.004), less likely to have an abnormal MOCHA profile (55% vs 36%, p=0.008) and had a shorter duration of follow-up (mean months 13 vs 7, p=0.0001). Cohorts had similar rates of the composite endpoint of AF, malignancy, VTE or other defined hypercoagulable disorder (33% vs 26%, p=0.43). MOCHA profile was obtained a median of 33 (IQR 15-57) days after index stroke in cohort 2; 41 (36%) patients were offered the option of anticoagulation therapy due to an abnormal MOCHA profile of which 32 (78%) chose anticoagulation. Cohort 2 had significantly lower rates of recurrent stroke than cohort 1 (14% vs. 0.9%, IRR 0.14, p=0.01) with no major hemorrhages seen in either group.

Conclusion:
This study suggests that anticoagulation therapy in a subgroup of ESUS patients with abnormal MOCHA profile may be associated with a reduced rate of recurrent stroke. A prospective, randomized study is needed to confirm these findings.
Abstract WP537: Attenuation of Blood Brain Barrier (BBB) Disruption by Chlorpromazine and Promethazine After Ischemic Stroke
Authors: Stone Christopher R , Li Fengwu , Ding Yuchuan , Geng Xiaokun
Published: January 2019

Introduction:
Blood-brain barrier (BBB) disruption is a common and serious complication in the pathogenesis of ischemic stroke. Although this disruption is known to exacerbate ischemic damage, and thus to serve as a poor prognostic indicator for patients, there is currently no treatment that has been clinically proven to prevent it. In previous studies, we have demonstrated the capacity of phenothiazine neuroleptics (combined chlorpromazine and promethazine, C+P) to exert a depressive or hibernation-like effect on brain metabolism, leading to neuroprotection following ischemia/reperfusion in rats. In this study, we tested the hypothesis that this depressive effect exerts its neuroprotection through augmentation of BBB integrity.

Methods:
Sprague-Dawley rats were subjected to 2h MCA occlusion followed by 6 or 24 h reperfusion, upon which they received an intraperitoneal injection of saline or C+P (8 mg/kg). 24h after reperfusion, neuroprotection was assessed by measuring infarct volume and neurological deficit. At 6 and 24h after reperfusion, BBB permeability was quantified by extent of brain edema, Evans blue leakage, and expression of BBB integral proteins aquaporin-4 and -9 (AQP-4, AQP-9), matrix metalloproteinase-2 and -9 (MMP-2, MMP-9), zonula occludens-1 (ZO-1), claudin-1/5, occludin, and laminin.

Results:
Infarct volume, neurological deficit, and BBB damage were all attenuated by C+P. C+P induced hypothermia; when this was controlled to physiological levels, however, C+P still conferred neuroprotection, suggesting the independence of its neuroprotective and hypothermic effects. C+P also significantly reduced post-stroke increases in AQP-4, AQP-9, MMP-2, and MMP-9, and reversed post-stroke decreases in tight junction (ZO-1, claudin-1/5, occludin) and basal laminar protein (laminin) levels.

Conclusion:
Post-ischemic C+P treatment exerts a powerful neuroprotective effect, characterized by reduced infarct volume, improved functional neurological deficits, decreased brain edema, and attenuated BBB breakdown through improvements in microvascular integrity and reinforcement of the basal lamina. Moreover, the safety and ubiquity of these drugs suggests significant clinical translatability for this therapy.
Abstract WP544: Dynamic Cerebral Autoregulation is Impaired in the First Week Postpartum in Women With and Without Preeclampsia
Authors: Miller Eliza C , Dos Santos Ketson , Wapner Ronald , Kougioumtzoglou Ioannis , Marshall Randolph
Published: January 2019

Introduction:
Pregnancy, especially when complicated by preeclampsia (PEC), is associated with increased stroke risk in the early postpartum period. Impaired cerebral autoregulation may play a role in the etiology of postpartum stroke. We compared dynamic cerebral autoregulation (DCA) in 3 groups of young women: healthy non-pregnant (HNP), healthy postpartum (HP), and postpartum after severe PEC.

Methods:
We recruited pregnant women with and without severe PEC and compared them with historical HNP controls. Pregnant women were tested within 1 week postpartum. Subjects were monitored for 10 minutes while breathing spontaneously, using transcranial Doppler to record cerebral blood flow velocity (CBFV) in the bilateral middle cerebral arteries and finger plethysmography to record continuous mean arterial pressure (MAP). We used generalized harmonic wavelets, a combined time-frequency method, to calculate the phase shift in degrees between MAP and CBFV, with higher phase shift indicating better DCA. We compared mean phase shift between the three groups using ANOVA.

Results:
Data collected from 6 non-pregnant, 5 HP and 5 PEC women were analyzed. Mean phase shift was 46.3 in the HNP, 21.2 in the HP group and 30.0 in the PEC group (p<0.0001). When compared pairwise, the HP and PEC groups each had lower mean phase shift compared to non-pregnant women (p<0.001) (Figure).

Conclusion:
In the first week postpartum after healthy and PEC-complicated pregnancies, women had poorer DCA capacity compared with healthy young non-pregnant women. The early postpartum period may be associated with impaired autoregulation, leading to increased stroke risk, particularly in women with labile blood pressure such as occurs in PEC.
Abstract WP554: Nationwide Survey of CADASIL in Japan
Authors: Shindo Akihiro , Tabei Ken-ichi , Taniguchi Akira , Onodera Osamu , Ando Yukio , Ihara Masafumi , Mizuno Toshiki , Tomimoto Hidekazu
Published: January 2019

Objectives:
Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is one of the common type of hereditary small vessel disease. The clinical presentation of CADASIL has been reported as varies, and there may exist the racial gap between Asian and Caucasian people. However, the clinical features of CADASIL in Japan is still unclear. This study aimed to elucidate the epidemiological and clinical features of CADASIL based on the nationwide survey in Japan.

Methods:
Target subjects were patients with CADASIL who had visited the certified hospitals (totally 1, 448 hospitals) by Japanese Society of Neurology and/or Japan Stroke Society in 2016. This study consisted of two steps surveys; patients with CADASIL were identified genetically by the first questionnaire, and their clinical features were assessed by the second questionnaire. Selected 6 hospitals registered the data of patients with CADASIL to REDCap system.

Results:
Based on the Japanese criteria (Mizuta et al. 2017), 88 patients (50 males and 38 females) with definite CADASIL were reported. Mean age at symptom onset was 49.4 years. Late onset (> 60 years) patients were 15 (17.0%), episode of migraine was detected in 26 patients (29.5%), and patients who had vascular risk factor(s) were 33 (37.5%). Stroke-like episodes with neurological signs were detected in 59 patients (67%), cognitive impairment in 31 patients (35.2%), pyramidal sign in 41 patients (46.6%), and pseudobulbar palsy in 20 patients (22.7%). Abnormal deep white matter lesions (WMLs) were detected in 85 patients (96.6%), WMLs extending to anterior temporal pole in 73 patients (83.0%), and cerebral microbleeds in 41 patients (46.6%).

Conclusions:
Although, CADASIL is characterized by early onset of stroke and without vascular risk, there were more than a few CADASIL patients with late onset and vascular risk factors in Japan.
Abstract WP555: Plasma Beta-Secretase 1 in Cerebral Amyloid Angiopathy
Authors: Su Ya , Gao Feng , Dong Qiang , Shen Yong , Cheng Xin
Published: January 2019

Backgrouds:
Beta-secretase 1 (BACE1) is the rate-limiting enzyme in amyloidogenesis. We have recently reported that plasma BACE1 activity may predict Alzheimer’s disease as surrogate biomarkers, and BACE1 protein and activity levels are increased in cortical vessels from patients with cerebral amyloid angiopathy (CAA). However, little is known about the plasma BACE1 levels in CAA.

Methods:
A single-center prospective cohort of probable CAA patients admitted to Huashan Hospital from December 2014 to September 2017 were age, sex and education matched with elder adults from population-based Shanghai Aging Study cohort. We collected the clinical data, plasma and imaging markers. We measured plasma BACE1 concentration with our in house ELISA and BACE1 activity as we recently described. BACE1 concentration and activity were compared between CAA and controls and within CAA patients according to disease severity using generalized linear models.

Results:
There were 40 CAA patients with mean age of 73.3 years and 41 controls of 72.8 years. Compared with heathy controls, CAA patients showed a higher BACE1 protein concentration (5.44 [3.39, 9.17] ng/ml vs. 7.37 [5.38, 11.88] ng/ml, p=0.009), higher BACE1 activity (218.8±96.0 mFU/min vs. 285.7±119.4 mFU/min, p=0.007) and higher BACE1 activity per total plasma protein (6.99.0±3.07 mFU/min vs. 9.01±4.27 mFU/min, p=0.017), with no significant differences in BACE1 activity-to-concentration ratio (32.46 [20.11, 70.46] vs. 34.27 [17.23, 54.12], p=0.484). A cutoff value of BACE1 activity 252.6 mFU/min was determined to differentiate CAA from healthy elders with a sensitivity of 0.575 and a specificity of 0.683. For CAA patients, plasma BACE1 activity was higher in the severe group (total SVD score ≥4, n=10, 371.62±110.09 mFU/min) than in the mild group (total SVD score <4, n=30, 257.04±109.61 mFU/min, p=0.012). No significant differences were found in CMBs>10 vs. CMBs≤10 group (p=0.600).

Conclusions:
Plasma BACE1 concentration and activity are increased in CAA patients. Our results indicate that plasma BACE1 may be a promising biomarker for CAA diagnosis and have potential values in disease severity grading. A larger CAA cohort has been recruited to further validate the results.
Abstract WP559: The NIH Toolbox Cognition Battery Outperforms the MoCA in Detecting Cognitive Impairment Following Mild Stroke in Young Patients
Authors: Rebchuk Alexander D , Deptuck Halina M , Kuzmuk Leah E , Silverberg Noah D , Field Thalia S
Published: January 2019

Introduction:
Current Canadian and US guidelines recommend screening for post-stroke cognitive impairment using the Montreal Cognitive Assessment (MoCA), and this metric is often used to assess cognition in stroke trials. The MoCA, however, may lack sensitivity to detect cognitive impairment in young, high-functioning patients with subtle cognitive deficits. We compared differences in performance between the NIH Toolbox-Cognition Battery (NIHTB-CB, an iPad-based 30-minute test that normalizes scores for age, sex, education and ethnicity), and the MoCA in young (18-55 years old), high-functioning (mRS 0-1) people with stroke and age-matched healthy controls.

Methods:
Recruitment for a target sample size of 120 is ongoing. To date, 21 healthy controls and 21 post-stroke participants are enrolled. Group differences in MoCA, NIHTB-CB fluid cognition, NIHTB-CB crystalized cognition and NIHTB-CB total cognition composite scores were compared using independent t-tests. Effect size of mean differences were calculated using Cohen’s d. The health utility of each group was measured with the EQ-5D.

Results:
Only the NIHTB-CB fluid cognition and total cognition scores were significantly worse for stroke patients compared to healthy controls, although there was a trend towards lower scores for the NIHTB-CB crystalized cognition and MoCA in the post-stroke group (Table). Stroke patients were 5.3 ± 5.6 months post-stroke. EQ-5D scores were lower for the post-stroke group, indicating worse health status.

Conclusions:
Our preliminary findings suggest that the NIHTB-CB may be a time-efficient alternative to the MoCA. The NIHTB-CB fluid and total cognition composite scores appear better suited than the MoCA for investigating cognitive impairments in young, mildly disabled stroke patients.
Abstract WP56: Distal Combined Technique; Combined Approach of Stent Retriever Assisted Aspiration Catheter to Distal Intracranial Vascular Embolectomy
Authors: Miura Masatomo , Shindo Seigo , Terasaki Tadashi , Namitome Satoshi , Wada Kuniyasu , Sugimura Yusuke , Nakajima Makoto , Ando Yukio
Published: January 2019

Background:
In acute ischemic stroke patients with distal intracranial vessel occlusion, efficacy of endovascular therapy remains debatable. A combined approach of stent retriever-assisted aspiration catheter for distal intracranial vessel occlusion (Distal combined technique; DCT) has potential for better recanalization rate than traditional techniques. The aim of this study was to investigate the efficacy of DCT.

Methods:
We evaluated consecutive acute ischemic stroke patients with distal anterior circulation artery occlusions including M2/M3 or A2/A3 segment, who underwent endovascular therapy from January, 2016 to June, 2018 in our center. Angiographical findings (modified Thrombolysis in Cerebral Ischemic [mTICI] score, including TICI 2c category), number of procedures, the processing time from puncture to reperfusion, favorable clinical outcome at 90-day (modified Rankin Scale [mRS] ≤ 2), and any symptomatic intracranial hemorrhage were compared between the DCT group and the non-DCT group.

Results:
Of 49 patients (mean aged 76 ± 11 years; 25 (51%) women; median NIHSS score at baseline 15), 17 (35%) were treated with DCT. Occlusion site was M2 in 25 patients, M2-3 in 18, and A2/A3 in 6. In the DCT group, higher reperfusion rates at the first pass (mTICI ≥ 2b, 94% vs. 53%, p = 0.003; mTICI ≥ 2c, 76% vs. 15%, p < 0.001; mTICI3 52% vs. 12%, p = 0.005), less number of procedures (median 1 vs. 2, p < 0.001), and shorter time from puncture to successful reperfusion (mean 33 min. vs. 53 min., p = 0.002) were observed. After all the endovascular procedures, the final successful reperfusion rate was also higher in the DCT group than in the non-DCT group (mTICI ≥ 2b, 100% vs. 84%, p = 0.148; mTICI ≥ 2c, 88% vs. 53% p = 0.025; mTICI3, 70% vs. 43%, p = 0.131). Symptomatic intracranial hemorrhage occurred in 1 patient in each group. A higher trend was observed in the rate of mRS ≤ 2 at 90 days in the DCT group (83% vs. 52% p = 0.083) compared to the non-DCT group.

Conclusions:
In patients with distal intracranial vessel occlusion, combined approach of stent retriever-assisted aspiration catheter is safe and efficacious; possibly leading to favorable long-term outcome.
Abstract WP565: Inhibition of Alpha5Beta1 Integrin as a Novel Therapy for Experimental Vascular Dementia
Authors: Roberts Jill M , Bix Gregory J
Published: January 2019

One of the prominent ways that ischemic brain injury expands is via disruption of the blood-brain barrier (BBB), allowing for increased edema and infiltration of inflammatory cells. Extracellular matrix proteins and their receptors are important contributors to the BBB. Notably, brain endothelial cell α5β1 integrin, a fibronectin receptor, is primarily expressed by brain endothelial cells during development, but increases following an injury such as ischemic stroke. We have previously shown that blockade of α5β1 integrin (via a small peptide ATN-161) after experimental stroke in mice leads to decreased infarct volumes, decreased leukocyte infiltration, and improved functional outcome. In addition, α5KO mice demonstrate improved BBB integrity and increased expression of the TJ protein claudin-5 following stroke compared to control mice. As disruption of the BBB is a key pathologic event in multiple cerebrovascular pathologies,
we hypothesized that blockade of α5β1 integrin with ATN-161 could also be therapeutic in vascular contributions to cognitive impairment and dementia (VCID)
, a prominent cause of dementia behind Alzheimer’s disease. VCID may occur, at least in part, as a result of chronic cerebral hypoperfusion, and eventually leads to white matter lesions, BBB disruptions and cognitive impairment. Here, we used the bilateral carotid artery stenosis (BCAS) model of chronic hypoperfusion, using 0.18 mm ID micro-coils wrapped around the carotid arteries of C57Bl/6 (male, 3 mo) mice to decrease, but not eliminate, blood flow to the brain. Interestingly, we observed a significant (p ≤ 0.001) increase in α5β1 integrin expression within 14 days post-stenosis and blockade of α5β1 integrin with ATN-161 (1 mg/kg; i.p.) significantly decreased α5β1 integrin expression. In addition, ATN-161 treatment significantly (p ≤ 0.01) decreased astrocyte activation (GFAP immunoreactivity) which occurs in the striatum following BCAS. Preliminary data also indicate improved cognitive outcome (Y-maze) with ATN-161 treatment as compared to controls. Collectively, these data indicate that α5β1 integrin may play a key role in a model of vascular dementia, and that inhibiting it with ATN-161 may stabilize the BBB and thereby slow or prevent disease progression.
Abstract WP568: The Effect of Pre-existing Mild Cognitive Impairment on Receipt of Treatments and Process Measures for Acute Ischemic Stroke
Authors: Levine Deborah A , Galecki Andrzej T , Kabeto Mohammed U , Nallamothu Brahmajee , Zahuranec Darin , Morgenstern Lewis B , Lisabeth Lynda D , Giordani Bruno , Langa Kenneth M
Published: January 2019

Background:
Mild cognitive impairment (MCI)—measurable cognitive impairment that doesn't severely affect daily functioning—is common, affecting 1 in 5 adults 65 or older. Little is known about the quality of stroke care for patients with pre-existing MCI despite evidence in other diseases that these patients may be under-treated.

Methods:
Prospective study of 708 patients aged ≥65 hospitalized with acute ischemic stroke between 2000 and 2014 from the Health and Retirement Study with linked Medicare and American Hospital Association data. We compared receipt of process measures after acute ischemic stroke between patients with pre-existing MCI (based on modified Telephone Interview for Cognitive Status [TICS-m] score, 7-11, a valid measure of MCI) and normal cognition (TICS-m score, 12-27). We used Cox regression to estimate the effect of pre-existing MCI on receipt of process measures after adjusting for patient and hospital factors (Table 1).

Results:
Patients with pre-existing MCI, compared to those with normal cognition, were less likely to receive IV t-PA, carotid revascularization, cardiac monitoring, and rehabilitation assessment, but not carotid imaging (Table 1). Pre-existing MCI was not independently associated with stroke process measures after adjusting for patient and hospital factors such as sex, educational and marriage status, and facility size.

Conclusion:
Modest differences in use of IV t-PA, carotid revascularization, rehabilitation assessment, cardiac monitoring, and carotid imaging exist in patients with pre-existing MCI and normal cognition after acute ischemic stroke. These differences were largely explained by patients with MCI being more likely to be women, less educated, unmarried, and using smaller hospitals.
Abstract WP570: Associations Between Stroke Symptoms and Cognition in Nepal
Authors: Fitzpatrick Annette L , Shrestha Rajeev , Shrestha Archana , Koju Rajendra , Shrestha Karmacharya Resha , Pant Basant , Karmacharya Biraj
Published: January 2019

Introduction:
Low and middle income countries have the largest burden of stroke, accounting for more than 85% of stroke deaths globally. As many low- and middle-income countries, including Nepal, transition from communicable to non-communicable diseases (NCDs), the impact of stroke on cognition becomes increasingly important.

Methods:
Data on cardiovascular risk factors and cognition were collected as part of the Dhulikhel Heart Study, a longitudinal study to evaluate risk factors for heart disease and stroke in Dhulikhel, a community outside of Kathmandu, Nepal. In Phase 1 of the baseline exam, 252 randomly-selected adults age 50 and older completed the Mini-Mental Exam (MMSE) and Digit Spans ( DST) forward and backward as part of a home interview. Mild stroke symptoms were collected by self-report the Questionnaire for Verifying Stroke-Free Status (QVSFS). Multiple linear regression evaluated associations between stroke symptoms and cognition adjusted for demographics (age, sex, education, religion, and ethnicity) and CVD risk factors (smoking, exercise, BMI, blood pressure, hypertension, and diabetes).

Results:
Mean age of study participants was 62.4 years (SD 9.2) and 57.5% were women. The mean MMSE score (weighted for illiteracy) was 18.7 (SD 6.4) and 19% reported to have had at least one of five stroke symptoms (sudden one-sided numbness or weakness, sudden vision-loss, inability to express oneself or inability to understand). An increased risk of lower memory score was found with report of a previous episode of numbness (DST backward: B=-1.17, SE=0.34, p=0.001). Borderline associations (.05 < p<.10) were found between any stroke symptoms and Digit Span forward, numbness and MMSE, and numbness and DST forward. When adjusted for demographic and cardiovascular risk factors, significant associations were found between having experienced any stroke symptom and Digit Span backward (B=-1.46, SE=0.66, p=.03) as well as numbness (B=-1.75, SE=0.72, p=0.02).

Conclusions:
Associations between previous stroke symptoms and reduced cognition emphasize the need to screen and treat persons with undiagnosed stroke or TIAs in low-resource settings. A reduction in modifiable vascular risk factors is also needed to reduce CVD and associated dementia.
Abstract WP65: Relationships Between Brain Perfusion and Early Recanalization After Intravenous Thrombolysis for Acute Stroke With Large Vessel Occlusion
Authors: Baron Jean Claude , seners pierre , Turc Guillaume , Lion Stephanie , Mas Jean-Louis , Oppenheim Catherine ,   Predict-Recanal Collaboration
Published: January 2019

Introduction:
In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-intravenous thrombolysis (IVT) recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following IVT administration in LVO patients.

Methods:
From a multicentre registry, 218 thrombolysed LVO patients referred for thrombectomy since May 2015 with both i) pre-IVT MRI, including diffusion-weighted imaging (DWI), T2* imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and ii) recanalization evaluated on first angiographic run or non-invasive imaging ≤3hrs from IVT start, were identified. Infarct core volume on DWI, PWI-DWI mismatch volume and Hypoperfusion Intensity Ratio (HIR; defined as the proportion of Tmax>6s volume with Tmax>10sec), a validated index of hypoperfusion severity, were determined using commercially available software.

Results:
Early recanalization occurred in 34 (16%) patients, and was independently associated with lower HIR (
P
=0.006), shorter thrombus on T2* imaging (
P
<0.001) and more distal occlusion (
P=
0.006). DWI lesion volume and PWI-DWI mismatch volume both had significant univariable association with recanalization but were not retained in the multivariable model. In addition, there was a significant interaction between thrombus length and HIR such that the effect of lower HIR on recanalization was stronger for smaller thrombi.

Conclusion:
This study disclosed a novel, independent association between milder hypoperfusion severity, as assessed by the HIR, and early post-IVT recanalization. Perfusion imaging may help to identify LVO patients most likely to benefit from IVT before thrombectomy.
Abstract WP70: Artificial Intelligence Based Detection of Large Vessel Occlusion on Non-Contrast Computed Tomography in Stroke
Authors: Tolhuisen Manon L , Ponomareva Elena , Koopman Miou S , Jansen Ivo G , Boers Anna M , Majoie Charles B , Marquering Henk A
Published: January 2019

Introduction:
Rapid detection of a large vessel occlusion (LVO) in acute ischemic stroke is beneficial as it may accelerate therapeutic management. The hyperdense artery sign (HAS) on non-contrast CT (NCCT) is result of an acute thrombolytic occlusion and is known as the earliest radiological marker to identify LVO. However, HAS is not apparent for all LVOs and detection by a less-trained eye can be sub-optimal. Artificial intelligence (AI) may support the non-trained radiologist in swift and accurate LVO detection. We evaluated the LVO detection accuracy of AI, and compared this to human expert performance.

Materials and Methods:
We used a convolutional neural network (CNN) developed by Nico.lab (www.nico-lab.com) that automatically detects and segments thrombi on NCCT using a patch-based approach. The CNN was trained using thrombus and non-thrombus patches, combined with the contralateral side. In a retrospective analysis of thin-slice NCCTs, obtained from Amsterdam UMC patients, with (ICA-T, M1, or M2) and without occlusions (stroke mimics), the CNN and two observers (>15y and >4y of experience) assessed LVO-presence and location. Ground truth was established by consensus between two different experts with >5y of experience, using both CTA and NCCT. Thrombus segmentations were considered accurate if segmentations overlapped with the ground truth. Sensitivity and specificity of the LVO detection were assessed.

Results:
We included 107 patients, of which 59 had proven LVOs. Nico.lab CNN showed a thrombus segmentation accuracy of 81%, vs. 81% and 77% of human experts. Sensitivity of LVO detection by CNN was 0.86, vs. 0.95 and 0.79 for human observers. Specificity was 0.65 for the CNN vs. 0.58 and 0.82 for human experts respectively.

Conclusion:
AI-based LVO detection on NCCT showed comparable results to expert observers. This supportive tool could lead to earlier detection of LVO in acute stroke situations. Fig 1A. HAS; B. CNN output (red); C. clot on CTA (blue arrow)
Abstract WP73: Brain Health Predicts Outcome in Patients With Intracerebral Hemorrhage
Authors: Vagal Vaibhav , Mistry Eva A , Behymer Tyler P , Sawyer Russell P , Stanton Robert J , Flaherty Matthew L , Moomaw Charles J , Sanford Carson V , Sekar Padmini , Coleman Elisheva R , Woo Daniel
Published: January 2019

Introduction:
Intracerebral hemorrhage (ICH) results in high mortality and high rate of disability among survivors. The effects of preexisting small vessel disease (SVD) on functional outcomes after ICH is uncertain and understanding manifestations of brain health such as white matter lesions (WML) and atrophy are a top priority for developing prognostic indicators. Our objective was to determine whether WML and brain atrophy is associated with functional outcomes in ICH patients.

Hypothesis:
We hypothesized that higher burden of WML and atrophy will have a poor outcome independent of age, ICH volume, ICH location, IVH, and presenting Glasgow Coma Scale (GCS) score.

Methods:
The Genetic and Environmental Risk Factors for Hemorrhagic Stroke (GERFHS) III study is a prospective study of hemorrhagic stroke in the Greater Cincinnati/Northern Kentucky region. We utilized the interviewed cohort from the study and systematically graded WML using the Van Swieten Scale (0-4) and measured brain atrophy (2 linear measurements) in baseline head CT scans. The outcome measures included modified Rankin Scale (mRS) at 3 months. Primary outcome was disability or death (mRS 3-6).

Results:
A total of 441 CT scans were graded; 48 patients were excluded due to missing mRS. Among the included 393 ICH patients (mean±SD age 71.5± 13.8; 48% females), old age, high ICH volume, low GCS score, severe WML (Van Swieten score 3-4), and atrophy were significantly associated with poor outcomes (mRS 3-6) in univariate analysis. In multivariate analysis, severe WML (p=0.039), atrophy (p= 0.0131), old age (p<0.0001), GCS (p<0.001), ICH location (p<0.0001 for deep, p=0.0033 for infratentorial) and ICH volume (p<0.0001) were associated with poor outcomes.

Conclusion:
Poor brain health manifesting as cerebral SVD markers of WML and atrophy are simple and independent baseline predictors of poor outcome in acute ICH. Further study for inclusion into outcome measures such as ICH Score should be considered.
Abstract WP81: Initial Experiences With Artificial Neural Networks in Detection of CT Perfusion Deficits
Authors: Vargas Jan
Published: January 2019

Background:
Head CT with perfusion imaging has become crucial in the selection of patients for treatment for mechanical thrombectomy. In recent years machine learning has rapidly evolved and found applications in a wide variety of health care tasks.

Objective:
We report our initial experiences with training a neural network pipeline to predict the presence and sidedness of a perfusion deficit in patients with acute ischemic stroke, based on imaging alone.

Methods:
CT perfusion images of patients with suspicion for acute ischemic stroke were retrospectively obtained. Each study was preprocessed into 3 dimensional arrays of Hounsfeld Units stacked through time, segmented to exclude bone, and then normalized. Labels were derived from the attending neuroradiologists’ read. The data was split into training and validation sets. A long term, recurrent convolutional (LRCN) network was constructed consisting of a convolutional neural network stacked on top of a long short term (LSTM) layer.

Results:
139 (35.1%) patients had a right sided perfusion deficit, while 199 (50.3%) had a left sided deficit, and 58 (14.6%) had no evidence of a deficit. The best model was able to achieve an accuracy of 85.8% on validation data. Receiver Operating Characteristic (ROC) curves were generated for each class and an Area Under the Curve (AUC) was calculated for each class. For a right sided deficit, the AUC was 0.90, for left sided deficit 0.96, and for no deficit the AUC was 0.93.

Conclusion:
The field of machine learning, powered by convolutional neural networks for the task of image recognition and processing, has quickly developed in recent years. We have constructed an artificial neural network that can identify and classify the presence and sidedness of a perfusion deficit CT perfusion imaging.