bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P312: Sensitivity to Mental Illness and Life Enjoyment (smile) After Stroke
Authors: Wu Matthew , Solano Laura , Degiorgio Christopher , Rao Neal M
Published: March 2021

Background:
After experiencing a life changing stroke, survivors are often faced with a challenging journey back to wellness. This is particularly trying for those with depression and poor access to healthcare. In this study, we seek to assess the degree of depression and health-related quality of life (QOL) in first-time ischemic stroke patients compared to post-myocardial infarction (MI) patients in a county hospital system.

Methods:
Consecutive patients admitted for stroke and MI at a Los Angeles County Hospital were reviewed. Patients who meet the inclusion criteria and consented for participation were assessed for quality of life with EQ-5D-3L, depression with Patient Health Questionnaire 9 (PHQ-9) and knowledge of mental health resources. Stroke and MI severity were ranked and compared by hospital length of stay and day 90 mRS. Dichotomized variables were computed via t-test for parametric and Wilcoxon for nonparametric values. Multivariate analysis of non-parametric values was computed via Spearman correlation.

Results:
61 stroke patients (mean age 59.7±13.4) and 52 MI patients (mean age 60.5±9.9) were included. Hospital length of stay did not significantly differ (mean 3.9 vs 2.5 days p=0.11). Day 90 mRS was significantly higher in the stroke group (mean 1.62 vs 0.96, p=0.004). PHQ-9 (mean 5.97 vs 6.85 p=0.13) and EQ-5D-3L (mean 7.4 vs 6.60 p=0.06) scores did not significantly differ. Among stroke patients (mean NIHSS 4.8 ±5.7), age correlated with day 90 mRS (r
s
=0.36 p<0.01). Initial NIHSS and stroke subtype did not correlate with either PHQ-9 or EQ-5D scores. Day 90 mRS correlated with PHQ-9 scores (r
s
=0.76 p<0.01, r
s
=0.65 p<0.01) and EQ-5D scores (r
s
=0.74 p<0.01, r
s
=0.78 p<0.01) in both groups. Only 6.5% of stroke and 15.1% of MI patients sought mental health resources.

Conclusions:
Stroke patients trended towards worse QOL scores, but lower depression scores than MI patients, though this did not reach statistical significance. Day 90 mRS correlated with worse QOL and depression scores in both groups. Despite high rates of depressive symptoms, very few patients had sought out mental health resources. This highlights the need to support mental health outreach, especially for vulnerable county patient populations.
Abstract P313: Feasibility of Nurse-Driven Identification of Depression in the Setting of Stroke at 30 Days Post Discharge
Authors: Mkrtumyan Alvina , Punsalang Lorina , Gaffney Denise , Cuenca Regina , Lapsys Katherine , Rojas Brenda , Dhanji Raeesa , Cheng Pamela , Le Duy , Sangha Navdeep S , Ajani Zahra
Published: March 2021

Background:
Poststroke depression (PSD) is under-recognized and affects the recovery and rehabilitation of stroke patients. PSD affects one-third of stroke survivors and there is little known when depressive symptoms manifest. Early identification of PSD may reduce its related functional impairment and mortality.

Purpose:
The purpose of this study is to demonstrate the feasibility of nursing driven depression identification at 30-45 days post discharge.

Methods:
All primary stroke patients received a phone call from SCRN to assess depression between 30 to 45 days post discharge using the Patient Health Questionnaire (PHQ9). Three attempts were made per patient. Data were analyzed from August 2019 thru March 2020. Based on the PHQ9 scores, patients were referred to different clinical care pathways. Patients who scored 1-9 received lifestyle modification information, 10-19 were referred to depression care management (DCM), 20 and above were referred to psychiatry. The number of patients evaluated and the percentage of those who were referred to specific pathways were assessed.

Results:
427 patients were discharged with a stroke diagnosis. 197 (46.1%) completed the PHQ9 assessment. 14 (7%) were ages 18 to 44 years, 65 (33%) were 45 to 64 years, and 118 (60%) were 65 years and above. 92 (47%) were female. 64% were Caucasian, 19% Asian, 13% Black, and 5% Other. 30% were Hispanic. 72% were ischemic, 19% ICH, and 9% SAH. 230 patients (53.9%) were not able to complete PHQ9. 88 (38%) were unavailable, and 120 patients (52%) were not able to participate due to stroke severity. 20 (10%) were referred to DCM and/or psychiatry.

Conclusions:
Nurse-driven 30-day PHQ9 assessment is feasible and identifies patients with depressive symptoms. The 30-45-day post-stroke timeframe may be reasonable to diagnose depression after an acute stroke.
Abstract P314: Mechanisms of Intracranial Atherosclerotic Disease Drive Hypoperfusion Patterns
Authors: Kim Song J , Yaghi Shadi , Honda Tristan , Scalzo Fabien , Hinman Jason D , Raychev Radoslav , Sharma Latisha K , Feldmann Edward , Romano Jose G , Prabhakaran Shyam , Liebeskind David S
Published: March 2021

Background:
In patients with symptomatic intracranial atherosclerotic disease (ICAD), borderzone infarct pattern and perfusion mismatch have each been shown to independently predict recurrent strokes, which may reflect the shared underlying mechanism of hypoperfusion distal to the intracranial atherosclerosis. As such, we hypothesized that perfusion volumes and patterns may correlate with various ICAD subtypes.

Methods:
A retrospective, 5-year analysis of consecutive ICAD patients with perfusion imaging for acute strokes (0-24 hours) due to sub-occlusive (50-99%) stenosis was conducted. The following subtypes were assigned based on the infarct pattern seen on the diffusion-weighted imaging (DWI): perforator, borderzone, and thromboembolic. Core volume on MRI and perfusion parameters on CT or MR perfusion, obtained concurrently or within 12 hours of MR DWI, were studied in each group.

Results:
42 patients (57% women, mean age 71±13 years old) with acute strokes received MRI imaging upon initial presentation. 15 were found with borderzone, 12 perforator, and 15 with thromboembolic pattern on DWI. Across all ICAD subtypes, median core volume (ADC <620) was 0 mL (0[0-6], 0[0-3], 0[0-7],
p
=0.95). Hypoperfusion with Tmax >4s and Tmax >6s delay volumes was significantly higher in the thromboembolic and borderzone infarct patterns compared to the perforator subtype (
Figure 1
). The volume difference between Tmax >4s and Tmax >6s (Δ Tmax>4s - Tmax>6s) was higher in the borderzone subtype compared to thromboembolism when analyzed pairwise.

Conclusion:
Core volume in ischemic strokes secondary to symptomatic ICAD is minimal. TMax>4 and TMax>6 parameters vary across the different ICAD patterns, with significantly large Tmax>4 delay volumes in the borderzone profile. Perfusion mapping may further elucidate hemodynamic mechanisms underlying ICAD.
Abstract P318: Ischemic Core Overestimation on Computed Tomography Perfusion
Authors: Garcia-Tornel Garcia-Camba Alvaro , Daniel Campos , Rubiera Marta , Sandra Boned , Olive-Gadea Marta , Requena Manuel , Ciolli Ludovico , Muchada Marian , Pagola Jorge , Rodriguez-Luna David , deck matias , Juega Jesus M , Rodriguez-Villatoro Noelia , Estela Sanjuan , tomasello alejandro , Piñana Carlos , Hernandez David , Alvarez-Sabin Jose , Molina Carlos , Ribo Marc
Published: March 2021

Introduction:
Different studies have pointed that CT perfusion(CTP) could overestimate ischemic core in early time window. We aim to evaluate the influence of time and collateral status on ischemic core overestimation.

Methods:
Retrospective single-center study including patients with anterior circulation large-vessel stroke that achieved reperfusion after endovascular treatment. Ischemic core and collateral status were automatically estimated on baseline CTP using available software. CTP-derived core was considered as tissue with a relative reduction of cerebral blood flow <30%. Collateral status was assessed using the hypoperfusion intensity ratio(defined by the proportion of the Tmax>6 seconds with Tmax>10 seconds, HIR). Final infarct was measured on 24-48 hours non-contrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct.

Results:
Four-hundred and seven patients were included in the analysis. Median CTP-derived core and final infarct were 7mL(IQR 0-27) and 20mL(IQR 5-55), respectively. Median HIR was 0.46(IQR 0.23-0.59). 83 patients(21%) presented ischemic core overestimation(median overestimation, 12mL(IQR 5-41)). Multivariable logistic regression analysis adjusted by CTP-derived core and confounding variables showed that poor collateral status (per 0.1 HIR increase, adjusted odds ratio(aOR) 1.41, 95% confidence interval(CI)1.20-1.65) and earlier onset to imaging time(per 60 minutes earlier, aOR 1.14, CI1.04-1.25) were independently associated with ischemic core overestimation. No significant association was found with imaging to reperfusion time(per 30 minutes earlier, aOR 1.17 CI0.96-1.44). Poor collateral status influence on ischemic core overestimation differed according to onset to imaging time, with a stronger size of effect on early imaging patients(pinteraction<0.01).

Conclusion:
In patients with large vessel stroke that achieve reperfusion after endovascular therapy, poor collateral status might induce higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time. CTP reflects a hemodynamic state rather than tissue fate; collateral status and onset to imaging time are important factors to estimate ischemic core on CTP.
Abstract P324: Your Brain May Be "HOTTER" Than You Think, Results From Phase I Check Brain Temperature Study
Authors: Wang David Z , Maksimovic Jane H , Mathews Maureen L , Liu Wen-Ching
Published: March 2021

Background:
Hypothermia is a known neuronal protecting agent and used in post cardiac arrest. However, its use for stroke and brain trauma has not made any progress due to the lack of accurate way of measuring brain temperature. Hence, hypothermic degree and duration for it to be therapeutic is unknown. The phase I Check Brain Temperature Study was to define regional brain temperatures in normal individuals via MRI thermometry. The established brain temperature map can be used as the baseline to provide therapeutic hypothermia.

Method:
Temperatures of 5 regions of interest (ROI) of brain (frontal lobe, thalamus, hypothalamus, occipital lobe and cerebellum) were measured in 10 healthy individuals by using proton resonance frequency MRI spectroscopy single voxel method. The scanning protocol include a whole brain anatomical images, (3DFSPGR : TR/TE=150/3.9ms, FOV=24cm,matrix=256x256, slice thickness =1 mm.) and spectroscopy PRESS (TR/TE=1500/144 ms, 8 nex, 2 x 2 x 2 cm^3) on a GE 3T scanner. Ten right handed men (18<age<80) were recruited and their oral and tympanic temperatures were monitored. Average whole head temperature=average of oral temp+tympanic temp and average brain temp=average of temp of 5 regions of interest. Two tails, paired t-test used to compare temps between subjects and ROIs.

Results:
Average temperature differences between brain (38.2 °C) and head (36.5 °C) is 1.8 °C (p< 0.0000002). Thalamus has the highest temperature among all ROIs in brain. Brain temperature > oral temperature > tympanic temperature.

Conclusion:
Brain temperatures may not correlate to body temperatures and there is a regional difference. Our finding will be used as the baseline brain temperature map when hypothermia is applied in patients with hemisphere stroke in the phase II study.
Abstract P327: Utilizing Iodine Contrast Extravasation Post Reperfusion and Dual Energy Ct Imaging to Predict Risk of Hemorrhagic Conversion in Acute Stroke Patients
Authors: Huynh* Tri , Vijayaraghavan* Niran , Branstetter Hannah , Buchwald Natalie , De Prey Justin , Dickens Rondalyn , Elfasi Aisha , Yu Crystal , Simpkins Alexis N ,   on behalf of the Univ of Florida CREST Initiative, *contributed equally
Published: March 2021

Introduction:
Hyperintense acute reperfusion marker (HARM) has been identified on post-contrast magnetic resonance imaging (MRI) to be a marker of hemorrhagic conversion (HC) post reperfusion therapy in acute stroke patients. We have previously described a case where MRI HARM was mimicked on post contrast computed topography (CT) imaging in an acute stroke patient post reperfusion. Dual-Energy (DECT) allows for differentiation between acute blood and iodine contrast extravasation (ICE), and thus can have utility when ICE is present. Here we sought to validate whether post-intervention ICE/CT hyperdensity reperfusion maker (CT HARM), and contrast subtracted on DECT is associated with HC in acute stroke patients.

Method:
Data was obtained from our Institutional Review Board approved stroke admission database from January 2017 to November 2019, including ischemic stroke patients that received thrombolysis or thrombectomy, had evaluable images within 24 hours of admission, and received a DECT. Ischemic volumes of the stroke was measured on diffusion-weighted image (DWI). ICE was measured on CT head and DECT using the freehand 3D region of interest tool on the Visage Imaging PACS System. Susceptibility weighted MRI sequences were used to grade HC. Data analysis was conducted with regression modeling.

Results:
A total of 82 patients were included, 49% women, median age 73 (interquartile range (IQR), 61- 77), admission NIHSS 12 (IQR, 7 - 21), 24 hour change in NIHSS 4 (IQR, 0 -13), glucose 125 (IQR, 106 -158), creatinine 1.0 (IQR, 0.8 - 1.2), infarct volume 50.6 ± 7.1 mL, 48% treated with thrombectomy, 7% with PH-1 or PH-2 identified on MRI, and 56% with MCA infarcts. ICE volume was 2.6 ± 1.0 mL and DECT volume was 2.2 ± 1.1mL. ICE increased the likelihood of MRI confirmed PH-1 or PH-2 hemorrhagic conversion (odds ratio (OR) 14.34, 95% confidence interval (CI) 5.74 - 22.94) and decreased likelihood of increase in NIHSS at 24 hours (OR 0.20, 95% CI 0.01 to 0.40). There were no other significant associations with ICE or DECT volumes.

Conclusion:
Our results are supportive of our proposed association between CT HARM and risk of HC. More studies are needed to study whether quantitative of DECT can be predictive of stroke outcomes post reperfusion therapy.
Abstract P329: White Matter Score Does Not Predict Post-tPA Hemorrhage in Elderly Patients Evaluated Acutely via Telestroke
Authors: Tariq Muhammad Bilal , Khanpara Shekhar , Bonfante Mejia Eliana , Zhu Liang , Ankrom Christy T , Trevino Alyssa , Joseph Michele , Zha Alicia , Cossey Tc , Wu Tzu-ching , Savitz Sean I , Jagolino-Cole Amanda L
Published: March 2021

Background:
While tPA may be safe in the elderly, increasing age appears to augment risk of post-tPA symptomatic intracranial hemorrhage (sICH). Age-related white matter changes (ARWMC) are associated with increased sICH. Patients evaluated for acute ischemic stroke (AIS) via telestroke (TS) may not have access to MRI to allow incorporation of microbleeds in tPA decisions. We assessed if increased CT-based ARWMC was associated with increased sICH in elderly patients.

Methods:
Patients 80 years and older who received tPA for AIS at spoke hospitals were selected from our TS network registry from 9/2015 to 12/2018. TS spoke CT scans from patient presentation were reviewed by three of the authors for periventricular white matter (PWMC) and deep white matter (DWMC) changes. Total ARWMC score, based on the Fazekas score, was collected. Total ARWMC score was either mild (0-2), moderate (3-4), or severe (5-6). PWMC and DWMC were either mild (0-1) or moderate-severe (2-3). Logistic regression adjusted for age, sex, race, ethnicity, NIHSS and premorbid mRS was used to analyze relationship of ARWMC scores with sICH and patient-outcomes.

Results:
Of 241 patients, median age overall was 86 years (IQR 83-90), and 66% were female. The overall median ARWMC score was 3 (IQR 2-5). Regression analysis showed that more severe ARWMC scores did not lead to higher frequency of post-tPA ICH (moderate OR 0.57, CI 0.19-1.71; severe OR 1.32, CI 0.48-3.65) including sICH (moderate OR 0.78, CI 0.21-2.94; severe OR 2.09, CI 0.62-7.02). Similarly, severe PWMC and DWMC were not associated with increased risk of post-tPA ICH (PWMC OR 1.31, CI 0.51-3.38; DWMC OR 1.25, CI 0.52-3.01), including sICH (PWMC OR 1.61, CI 0.51-5.08; DWMC OR 1.81, CI 0.65-5.01). In our cohort, older patients had no difference in hemorrhage (ICH OR 0.93 CI 0.85-1.00: sICH OR 0.95 CI 0.86-1.04), and patients with less severe stroke were more likely to have hemorrhage (ICH OR 1.06 CI 1.02-1.10; sICH OR 1.08 CI 1.03-1.13). IRR among the CT scan readers was moderate (k=0.504).

Conclusions:
ARWMC scores were not associated with post-tPA ICH in the elderly. Our analysis lends support for the use of tPA despite severity of white matter disease. ARWMC should not be used to assist in tPA decision-making in elderly patients via telestroke.
Abstract P330: Optimizing Predictions of Infarct Core Using Machine Learning
Authors: Abdelkhaleq Rania , Lopez-Rivera Victor , Salazar-Marioni Sergio , Lee Songmi , Kim Youngran , Giancardo Luca , Coronado Ivan , Tariq Muhammad , Khose Swapnil , Jeevarajan Jerome , Shahrivari Mahan , Savitz Sean I , McCullough Louise D , Sheth Sunil A
Published: March 2021

Introduction:
Evaluation of infarct core by advanced neuroimaging has facilitated patient selection for endovascular stroke therapy (EST), however the accuracy of machine-learning analysis compared to these modalities remains unexplored. We test the performance of computed tomography-Alberta Stroke Program Early Computed Tomography Score (CT- ASPECTS) vs. Computed Tomography Perfusion (CTP)-RAPID, vs. an extension of our novel machine-learning model, Deep Symmetry-sensitive Network (DeepSymNet [ref]), using the final infarct volume (FIV) in patients with rapid and successful endovascular reperfusion as the gold standard.

Methods and Materials:
We identified consecutive patients with large vessel occlusion acute ischemic stroke that underwent EST with TICI 2b/3 reperfusion. FIV was determined by volumetric measurements on 24-48h DWI MRI. The DeepSymNet algorithm combines symmetric and absolute brain representations and had been trained to predict CTP-RAPID core size from CTA source images acquired at presentation. Performance at predicting FIV was determined by Pearson’s correlation for CT- ASPECTS, CTP-RAPID, and DeepSymNet. Data are presented as median [IQR].

Results:
Among the 76 patients that met inclusion criteria, 55.2% were male, the median age was 68 years [54-77], and 32.8% were White. 71% of the patients demonstrated an MCA occlusion, and 55% of all occlusions were left-sided. Median ASPECTS on presentation was 8 [7-8.5] and the median FIV was 10 mL [2-37]. ASPECTS, CTP-RAPID and DeepSymNet all correlated with FIV, with comparable performances from ASPECTS (R
2
=-0.398) and CTP-RAPID (R
2
=0.403) and superior performance by DeepSymNet (R
2
=-0.606)(Table).

Conclusions:
The DeepSymNet machine learning model analyzing CTA source images demonstrated superior performance to ASPECTS and CTP-RAPID in FIV prediction. These findings suggest machine learning models may provide improved predictions of infarct core and selection for EST.
Abstract P338: Incidence, Predictors and Impact of Infarct in New Territory in Escape Na1 Trial
Authors: Singh Nishita , Marko Martha , Cimflova Petra , Ospel Johanna , Kashani Nima , Mayank Arnuv , Nogueira Raul G , Mctaggart Ryan A , Demchuk Andrew M , Poppe Alexandre Y , Hill Michael D , MENON Bijoy K , GOYAL MAYANK , Almekhlafi Mohammed
Published: March 2021

Introduction:
Infarct in new territory (INT) is a known complication of endovascular therapy. We assessed the prevalence, predictors and clinical relevance of INT

Methods:
We included patients from the ESCAPE-NA1: a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in patients with acute ischemic stroke who underwent EVT within 12 hours from onset. All imaging was re-evaluated, and INT was defined by presence of infarct in new vascular territory, outside the baseline target occlusion(s) on follow up CT and MRI. INT’s were classified by maximum diameter (<2mm, 2-20mm and >20mm) and location.

Results:
Of 1099 analyzed patients in ESCAPE NA1, 107 had INT (9.7%, mean age 67 years, 51.4% females). There were no differences at baseline in those with vs without INT. Most INTs (75.7%) were angiographically occult and 41(38.3%) were > 20mm. The most common INT territory was the ACA alone or in combination with MCA/PCA (30.3%). The presence of emboli in new territory angiographically was significantly associated with INT (OR 16.39, 95%CI 8.14-33.09). Alteplase use, balloon guide catheter use, nerinetide and initial occlusion site did not predict INT. INT patients had higher final median infarct volumes compared to non-INT (44.5cc vs 23.3cc, P<0.001). Large INT (diameter of >20mm) were associated with poor clinical outcome compared to INT (<2mm) OR (mRS 0-2) 0.17, 95%CI 0.05-0.55).

Conclusion:
Infarcts in new territory are common and are associated with poor outcome.
Abstract P35: The Trend of Stroke Rehabilitation Utilization Between 2014- 2019 in a Community Based Study
Authors: Uhm Daniel , Olasoji Esther , Simpkins Alexis N , Geis Carolyn ,   on behalf of the Univ of Florida CREST Initiative
Published: March 2021

Introduction:
Stroke is the leading cause of long-term disability in adults, resulting in significant impairments in motor, sensory, and/ or cognitive that often requires continued rehabilitation services, which vary from intensive acute inpatient rehabilitation to outpatient rehabilitation services. Efforts to reduce disability have advanced rapidly over the past several years. Our data analysis was undertaken to assess whether recent changes in clinical practice have impacted the proportion of stroke patients receiving inpatient versus outpatient rehabilitation over time between 2014-2019 at our institution, which serves a diverse mix of rural, suburban, and urban populations.

Methods:
Our Institutional Review Board approved retrospective stroke database, including adult patients discharged to receive rehabilitation services data from 2014-2019, was used for analysis. Cochran-Armitage trend analysis was used to assess for differences type of rehabilitation services used over time and regression analysis was used to identify clinical factors associated with discharge type over time.

Results:
A total of 3467 patients were included in the analysis, 50% woman, 1% Asian, 20% Black, 75% White, 4% undetermined race, 17% intracerebral hemorrhage, 65% ischemic stroke, 11% subarachnoid hemorrhage, 3% transient ischemic attack, 3% other cerebrovascular disease. In this community population, 65% were discharged to inpatient rehab. Trend analysis demonstrated a significant increase in the proportion of patients being discharged home with rehab services, p<.0001. In comparison to those discharged home, patients discharged to rehab were older (odds ratio (OR) 1.02, confidence interval (CI) 1.02-1.03), with a higher NIHSS (OR 1.16, CI 1.14-1.18), discharged in 2014 (OR 1.72, CI 1.23-2.39) or 2016 (OR 1.46, CI 1.05-2.05) versus 2019. There was no association with race, gender, or discharge in 2015, 2017, or 2018.

Discussion:
Our findings demonstrate the community impact of recent changes in clinical practice guidelines for stroke. The increasing trend of home discharges is encouraging, but the significant proportion of those still not discharged home suggests there is still more work to be done to reduce stroke associated disability in adults.
Abstract P356: Wernicke’s Vertical Occipital Fasciculus in Post-Stroke Reading
Authors: Keser Zafer , Meier Erin L , Stockbridge Melissa D , Breining Bonnie L , Sebastian Rajani , Hillis Argye E
Published: March 2021

Introduction:
The vertical-occipital fasciculus (VOF), which was initially described by Wernicke more than a century ago but recently rediscovered, connects visual association cortices to the posterior language areas. We hypothesized that the vertical-occipital fasciculus plays a critical role in reading.

Methods:
Thirty-two participants with subacute to chronic left hemispheric stroke leading to varying degrees of aphasia were enrolled in the study and underwent concurrent diffusion tensor imaging (DTI) and language assessment. Assessments included the Boston Diagnostic Aphasia Examination (BDAE) to assess oral reading and reading comprehension and the Boston Naming Test to assess picture naming. Two major cortico-cortical projection pathways, VOF, connected with posterior language cortices and frontal aslant tract (FAT), connecting anterior language areas, were mapped with deterministic tractography and quantified bilaterally. We conducted partial correlations between fractional anisotropy (FA) values of the tracts and reading and picture naming scores, controlling for age, education, and total lesion load. We corrected for multiple comparisons at the false discovery rate (FDR) (p<0.05).

Results:
FA of left VOF was found to be significantly correlated with BDAE total reading scores (r=0.49, p=0.004), and this remained significant after FDR correction (p=0.03). Although a significant correlation was seen between picture naming and left VOF FA (r=0.41, p=0.02), and right VOF FA (r=0.37, p=0.04), these associations were not significant after FDR correction (p>0.05). FAT FA values were not significantly associated with oral reading or picture naming tests.

Conclusion:
This study provides preliminary evidence that left VOF plays a potential role in reading after left hemispheric stroke.
Abstract P36: Lesional Perfusion and Permeability Are Diagnostic and Prognostic Biomarkers of Cavernous Angioma With Symptomatic Hemorrhage
Authors: Sone Je Yeong , Hobson Nicholas , Romanos Sharbel , Srinath Abhinav , Shkoukani Abdallah , Li Yan , Carrión-Penagos Julián , Stadnik Agnieszka , Piedad Kristina , Bi Dehua , Lightle Rhonda , Moore Thomas , Shenkar Robert , Carroll Timothy , Ji Yuan , Girard Romuald , Awad Issam A
Published: March 2021

Introduction:
Diagnosis of cavernous angioma with symptomatic hemorrhage (CASH) requires MRI evidence of lesional bleeding associated directly with attributable symptoms. However, hemorrhagic signs of CASH may become clinically silent on conventional MRI after 3 months. As CASH is likely to rebleed for several years, accurate diagnosis of CASH that bled more than 3 months prior is needed.

Hypothesis:
Perfusion and permeability derivations of dynamic contrast-enhanced quantitative perfusion (DCEQP) MRI can diagnose CASH and predict bleeding/growth in CAs.

Methods:
CAs of 205 consecutively enrolled patients scanned with DCEQP during clinical visits were classified as CASH that bled 3 - 12 months prior (N = 55) versus non-CASH (N = 658) or CA with (N = 23) versus without (N = 721) bleeding/growth within a year after MRI. Demographics and 13 perfusion and 13 permeability derivations of DCEQP were assessed via machine learning and univariate analyses. Logistic regression models ln (
P
/ 1 -
P
) = Σ (β
i
x
i
) + β
0
were selected as the best diagnostic and prognostic biomarkers by minimizing the Bayesian information criterion (BIC).

Results:
The best diagnostic biomarker of CASH that bled 3 - 12 months prior (BIC = 321.6, Figure A) showed 80% sensitivity and 82% specificity. Permeability derivations did not add diagnostic efficacy when combined with perfusion. The best prognostic biomarker of bleeding/growth (BIC = 201.5, Figure B) showed 77% sensitivity and 72% specificity.

Conclusion:
Perfusion imaging may diagnose CASH even after hemorrhagic signs disappear on conventional MRI. A combination of permeability and perfusion derivations may help predict bleeding/growth in CAs.
Abstract P368: Developing Automated Methods for Disease Subtyping in UK Biobank: An Exemplar Study on Stroke
Authors: Rannikmae Kristiina , Wu Honghan , Tominey Steven , Whiteley William , Allen Naomi , Sudlow Cathie L ,   on behalf of UK Biobank
Published: March 2021

Objective:
In UK Biobank (UKB), a large population-based prospective study, cases of many diseases are ascertained through linkage to routinely collected, coded national health datasets. However routinely collected coded data cannot always provide sufficient accuracy or granularity (i.e. sub-phenotypes) for research studies. For example, while ischemic stroke codes appear accurate, the precision for hemorrhagic stroke codes (intracerebral hemorrhage [ICH] and subarachnoid hemorrhage [SAH]) may be as poor as <50%. We investigated whether automated analysis of radiology reports could improve disease subtyping in UKB, using stroke as an exemplar disease.

Methods:
From a sub-population of 17,249 UKB participants, we ascertained those with an incident stroke code and ≥1 clinical brain scan report. We used automated methods (a combination of natural language processing and clinical knowledge inference) on brain scan reports to assign a stroke subtype (ischemic vs ICH vs SAH) for each participant and assessed performance by precision (positive predictive value) and recall (sensitivity) at both entity and patient levels.

Results:
Of 225 participants with an incident stroke code, 207 had a relevant brain scan report. Entity level precision and recall ranged from 78% to 100%. Automated methods showed precision (positive predictive value) and recall (sensitivity) at patient level that were very good for ICH (both 89%), good for SAH (both 82%), but, as expected, lower for ischemic stroke (73%, and 64%, respectively), suggesting coded data remains the preferred method for identifying the latter stroke subtype (Table 1).

Discussion:
Future research should validate these findings in another dataset.

Conclusion:
Our novel automated method applied to radiology reports provides a feasible, scalable and accurate solution to improve disease subtyping when used in conjunction with administrative coded health data.
Abstract P370: Early Brain Volume Change After Stroke: Subgroup Analysis From the Axis-2 Trial
Authors: Bu Ning , Churilov Leonid , Khlif Mohamed Salah , Lemmens Robin , Wouters Anke , Fiebach Jochen B , Ringelstein Erich Bernd , Laage Rico , Grond Martin , Norrving Bo , Chamorro Angel , Wilms Guido , Brodtmann Amy , Thijs Vincent
Published: March 2021

Objective:
The timing of brain atrophy after stroke is not well understood. We investigated the associations between age and imaging features and brain volume change in the first month after stroke.

Methods:
We retrospectively studied patients with acute ischemic stroke enrolled in the AXIS-2 trial. Total brain volume change from hyperacute MRI data to the first month after stroke was assessed using unified segmentation in SPM12. We hypothesized that age, ischemic brain lesion size and white matter changes were associated with larger brain volume change. Enlarged perivascular spaces (EPVS) and white matter hyperintensities (WMH) were rated visually and the presence of lacunes was assessed.

Results:
We enrolled 173 patients with a mean age of 67±11 years, 44 % were female. There was a median 6 mL decrease in volume (25th percentile -1mL-75th percentile 21mL) over time, equivalent to a median 0.5% (IQR-0.07% - 1.4%), decrease in brain volume. Age was associated with larger brain volume loss (per 10 years of age, 5 mL 95% CI 2 mL-8 mL). Baseline DWI lesion volume was not associated with greater volume loss (per 10 mL of lesion volume, change by 0 mL (95% CI -0.1 mL-0.1mL). Increasing Fazekas scores of deep white matter hyperintensity were associated with greater tissue loss (5 mL, 95% CI 1 mL-10 mL). Brain volume change was associated with ordinal change on the modified Rankin scale at 90 days (per 10 ml, OR 1.085, 95% CI 1.031-1.141) but the association was not present when adjusting for age, baseline diffusion lesion volume and NIHSS score (OR 1.044, 95% CI 0.990-1.010).Interpretation-Global brain volume loss occurs over 1 month after stroke and is associated with age and deep white matter disease. We did not find evidence that more severe strokes lead to increased early tissue loss.
Abstract P384: Outcomes of Endovascular Therapy in Patients With Pre-Stroke Mobility Impairment
Authors: Beekman Rachel , Sun Jie-Lena , Alhanti Brooke , Schwamm Lee H , Smith Eric , Bhatt Deepak L , Xian Ying , Shah Shreyansh , Lytle Barbara , Fonarow Gregg C , Sheth Kevin N
Published: March 2021

Background and Purpose:
Patients with pre-stroke mobility impairment were excluded from endovascular clinical trials. There is limited data regarding safety and outcomes of endovascular thrombectomy (EVT) in this population. We used a large, national dataset (Get With The Guidelines (GWTG)-Stroke) to evaluate the safety and outcomes of EVT in patients with pre-stroke mobility impairment (PSMI).

Methods:
We included patients who underwent EVT in the GWTG-Stroke registry between 2015 and 2019. PSMI was defined as inability to ambulate independently and poor outcome was defined as in-hospital mortality or discharge to hospice. GEE logistic regression models were used to evaluate the association between PSMI and outcomes.

Results:
Of 56,762 patients treated with EVT, 2919 (5.14%) had PSMI. Patients with PSMI were older (median 79 [IQR 70-87] vs 70 [59-80], P<0.001), more likely to be female (63.4% vs 49.2%, P<0.001), had more medical comorbidities, presented with a higher NIHSS (19 [12-24] vs 15 [9-21], P<0.001), and were less likely to be treated with tPA (36.8% vs 45.6%, P<0.001). PSMI was not associated with intracranial hemorrhage but was associated with poor outcome (Table 1). Patients with PSMI with poor outcomes were more likely to be older (83 [74-89] vs 77 [68-86], P<0.001) and have a higher presenting NIHSS (21 [16-25] vs 16 [11-22], p<0.001). Forty-nine percent of patients with PSMI with age >80 years and NIHSS >20 had a poor outcome.

Conclusions:
Amongst patients with PSMI treated with EVT, two thirds survived and one third were discharged to home or to inpatient rehabilitation. Advanced age and increased stroke severity increased the likelihood of poor outcomes. EVT appears safe in patients with PSMI, yet further study of effectiveness in this population is warranted.
Abstract P395: High Risk Diabetics Risk of Recurrent Stroke and Cardiovascular Disease Persists Even With Patient Personalized Subspecialty Care
Authors: Branstetter Hannah , Buchwald Natalie , Olasoji Esther , Humbert Meghan , Dickens Rondalyn , Huynh Tri , Vijayaraghavan Niran , Simpkins Alexis N ,   on behalf of the Univ of Florida CREST Initiative
Published: March 2021

Introduction:
Diabetes management is an important aspect of stroke prevention. To our knowledge, studies that focus specifically on the role of multidisciplinary teams for adjusting diabetes medications and diabetes education for stroke and cardiovascular disease prevention to compliment standard stroke prevention and nursing education are lacking. Here we sought to evaluate whether high risk diabetics, hemoglobin A1c (HA1c) > 8%, admitted secondary to stroke would benefit from a multidisciplinary team model that also incorporates endocrinology consultation and diabetes education to personalized nursing education and education and management of the admitting service.

Methods:
Data was obtained from our Institutional Review Board approved stroke admission database from 2017 to November 2019. Regression analysis was used to identify significant associations between diabetes education (DE) and endocrine consultation (EC) with readmission rates with 30 days, re-admission within 30 days secondary to stroke, cardiovascular event or stroke within a year of the stroke admission, and medication change after controlling for age, sex, NIHSS, HbA1c, low density lipoprotein (LDL), reperfusion therapy for acute stroke. Follow-up HbA1c post hospitalization was available for only 17% of the population, and was not included in the regression models.

Results:
A total of 202 patients were included, median age 66 (interquartile range 56-75), 43% women, NIHSS median 5 (interquartile range (IQR, 2-9), LDL median 105 (IQR, 69-155), A1c median 9.5 (IQR, 8.5 -11.1), and 24% received reperfusion therapy. EC was associated with higher likelihood of a medication change (odds ratio (OR) 9.43, 95% confidence interval (CI) (3.22-30.69). DE was associated with younger age (OR 0.96, 95% CI 0.92-0.99); higher A1c value (OR 1.47, 95% CI 1.18 - 1.87) and higher likelihood of cardiovascular event within a year of the stroke (OR 3.38, 95% CI 1.23 - 9.70).

Conclusion:
While the endocrine consultation does lead to medications changes with the intent of improving post discharge glycemic control, cardiovascular events were still more likely, possibly from DM disease severity. Further continuation of follow up of these patients with EC and DE after hospital discharge may be needed.
Abstract P399: Do Not Resuscitate Orders in Subarachnoid Hemorrhage Patients. Impact on Mortality
Authors: Chaudhry Mohammad Rauf , Gill Hussan , Chaudhry Saqib , Singh Baljinder , Bandaru Harathi , Vellipuram Anantha Ramana , Piriyawat Paisith , Maud Alberto , Rodriguez Gustavo J , Cruz-Flores Salvador
Published: March 2021

Introduction/background:
Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites.

Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all subarachnoid hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups.

Results:
Of the 325923 patients with SAH, 20127 (6.17%%) had DNR order. SAH patients with DNR order had higher proportion of females (61.7% versus 59.4%, P=0.0048) and were older (70.9 years versus 58.4 years, P <.0001) compared to SAH patients without DNR. The in-hospital mortality was also higher (66.4% versus 22.4%, p≤.0001) among patients with DNR both univariate and multivariate analysis (OR = 5.05 (4.58 -5.56), p<.0001) after adjusting for potential confounders. Whites have a higher rate (7.59% versus 5.84%, P <.0001) of DNR order as compared to other racial/ethnic groups

Conclusions:
While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.
Abstract P4: Predictors of Outcomes in Patients With Mild Ischemic Stroke Symptoms: Results From the Mild and Rapidly Improving Stroke Study (mariss)
Authors: Romano Jose G , Gardener Hannah , Campo-Bustillo Iszet , Khan Yosef , Tai Sofie , Riley Nikesha , Smith Eric , Sacco Ralph L , Khatri Pooja , Alger Heather , Schwamm Lee H ,   MaRISS Investigators
Published: March 2021

Background:
Although most strokes present with mild symptoms, these have been poorly represented in clinical trials. The objective is to describe multidimensional outcomes, identify predictors of worse outcomes and explore the effect of thrombolysis in this population.

Methods:
This prospective observational study included patients with ischemic stroke or TIA presenting with stroke symptoms and a baseline NIHSS 0-5 within 4.5 hours from symptom onset. The primary outcome was a 90-day modified Rankin Scale (mRS) 0-1; secondary outcomes included good outcomes in the Barthel Index, Stroke Impact Scale-16 (SIS-16) and European Quality of Life. Multivariable models were created to determine predictors of outcomes and the effect of alteplase.

Results:
A total of 1765 participants were included from 100 Get With The Guidelines (GWTG)-Stroke participating hospitals (age 65
+
14, 42% women, final diagnosis ischemic stroke 90%, TIA 10%, 57% received alteplase). At 90 days, 37% were disabled and 25% not independent. Worse outcomes were noted for older individuals, women, non-Hispanic Blacks and Hispanics, Medicaid, smokers, those with diabetes, atrial fibrillation, prior stroke, higher baseline NIHSS, visual field defects, arm and leg weakness. Similar outcomes were noted for the alteplase-treated and the untreated groups. Alteplase treated patients were younger (64
+
13 vs. 67
+
1.4) with a higher NIHSS (2.9
+
1.4 vs. 1.7
+
1.4). After adjusting for age, sex, race-ethnicity, and baseline NIHSS, we did not identify an effect of alteplase on the primary outcome but did find an effect on SIS-16 in the restricted sample of baseline NIHSS 3-5. Very few symptomatic hemorrhages were recorded (3/999).

Conclusions:
A large proportion of stroke patients presenting with a low NIHSS have a disabled outcome. Baseline predictors of worse outcomes are described. An effect of alteplase on outcomes was not identified in the overall cohort but an indication of efficacy was noted in the NIHSS 3-5 subgroup.
Abstract P404: Causes of Recrudescent Stroke Symptoms in Emergent Stroke Evaluations
Authors: Quinn Jeffrey , Hajighasemi Mohammad , Paletz Laurie , Figueroa Sonia , Schlick Konrad
Published: March 2021

Introduction:
Recrudescent symptoms of remote central nervous system lesions (primarily due to prior ischemic or hemorrhagic stroke) is a specific stroke mimic that is commonly in the differential diagnosis in patients presenting for emergent stroke evaluation. To date, best practices have yet to be established in terms of ensuring accurate diagnosis and the relative rates of causative systemic illnesses are not well described. We seek to better delineate the etiologies of recrudescent stroke symptoms seen at a tertiary care medical center via emergency stroke evaluation “Code Brain” (CB) as a first step towards clarifying diagnostic criteria for this entity.

Methods:
Data was obtained via retrospective chart review from consecutive patients via departmental database listing all CB consults seen at a tertiary care comprehensive stroke center in Los Angeles, California between the timeframe of January 2018- June 2020. Diagnoses for each case were adjudicated by faculty Vascular neurologists, in collaboration with Vascular neurology fellows and Neurology residents. Those cases with a diagnosis of stroke recrudescence were reviewed in detail for the extent of neuroimaging they underwent, as well as for identified causes of recrudescence.

Results:
Records of 3,998 consecutive CB activations were reviewed. 2.1% (n=85) were found after screening to have clinical diagnosis of recrudescence or chronic stroke. Of these 85 patients, 29.4% (n=25) were not found to have a causative etiology for recrudescent neurologic deficit. Of these 25 patients, 36.0% (n=9) did not undergo MRI to evaluate for interval ischemic lesion, as compared to 46.6% of those whom a causative etiology was identified. This difference (10.6%, 95% CI -12.30 to 30.67%, p=0.3719) was not significant.

Discussion:
At our comprehensive stroke center, recrudescent stroke is an uncommon diagnosis amongst all CB evaluations, despite being commonly considered. Despite a diagnosis of recrudescence, MRI brain is not always performed to rule out acute ischemic stroke. Standardized neuroimaging protocols should be considered in making the diagnosis of stroke recrudescence.
Abstract P415: Is Hemostatic Efficacy of Four Factor Prothrombin Complex Concentrate Similar in Intracerebral Hemorrhage Patients Receiving Warfarin vs Non-Vitamin K Anticoagulants?
Authors: Pon Gregory , Pelsue Brittany , Zhang Xu , Gulbis Brian , Reddy Sujan T , Parsha Kaushik N , Barreto Andrew D , Savitz Sean I , Allison Teresa A
Published: March 2021

Introduction:
Four Factor Prothrombin Complex Concentrate (4F-PCC) is indicated for reversal of warfarin-induced coagulopathy. In small cohort studies, 4F-PCC has similar hemostatic efficacy rates reversing non-vitamin K anticoagulants (NOACs). There are no comparison studies evaluating 4F-PCC for the reversal of warfarin versus NOACs in the setting of intracerebral hemorrhage (ICH).

Methods:
A multicenter retrospective cohort study was conducted between 2013-2020 at a comprehensive stroke system in ICH patients who received 4F-PCC for the reversal of warfarin or a NOAC. Patients were included if they were adults with an acute ICH, anticoagulant regimen of warfarin (INR 1.3 or greater) or NOAC, and 2 head CT scans within 24 hours to determine hemostatic efficacy. Hemostatic efficacy was evaluated by the Sarode scale. The chi square and t-test were used as appropriate for demographic and clinical data, with multivariable regression analysis conducted in a forward stepwise manner, retaining variables with significance less than 0.05.

Results:
One hundred fifty-seven patients were included (baseline characteristics in Table 1). There was no statistically significant difference in effective hemostasis observed between warfarin and NOAC patients (83% vs 75%, p=0.33). Similarly, multivariable analysis did not demonstrate a significant difference in effective hemostasis (OR 0.55, 95% CI: 0.2-1.3, p=0.2). However, due to wide 95% confidence intervals, we cannot exclude a key treatment effect from PCC. After controlling for baseline characteristics, patients treated with NOACs had 53% lower odds of a good clinical outcome compared to those treated with warfarin (Figure 1; OR 0.47, 95% CI: 0.2-1.3, p=0.13).

Conclusions:
In conclusion, there was no statistically significant difference in hemostatic efficacy or clinical outcomes between warfarin and NOAC patients following reversal with 4F-PCC.
Abstract P417: Critical Knowledge Gaps in Characterizing Cognitive Impairment Among Intracerebral Hemorrhage Patients: Systematic Review of Contemporary Literature
Authors: Potter Thomas , Meeks Jennifer , Khan Osman , Misra Vivek , Britz Gavin W , Seshadri Sudha , Woo Daniel , Vahidy Farhaan S
Published: March 2021

Introduction:
Despite emerging evidence, trajectories of cognitive impairment (CI) among patients with spontaneous intracerebral hemorrhage (ICH) are not well characterized.

Methods:
We conducted a systematic review of literature within PubMed, using keywords [“Intracerebral hemorrhage” OR “ICH”] AND “Cognitive Impairment,” after 2010. Articles reporting assessments of post ICH CI were included. Articles limited to pre-clinical (animal) studies, non-English literature, other intracranial hemorrhages, traumatic ICH, narrative reviews, and patient under 18 years were excluded.

Results:
Based on selection criteria, we included 16 articles (graphic) that provide an assessment of post-ICH CI. Post-ICH CI had a reported incidence of up to 85% within the first 2 weeks. The proportion of ICH patients who experience an incident CI across a longer follow up time period have been reported with a high degree of variability; with reports at 3 (32.5 - 71%), 4 (78%), 6 (37 - 63.3%), 9 (47.1 - 100%), 18 (51%), 30 (25.8%), 40 (23%), 45.6 (52 - 64%) and 60 (37.4%) months. Though the assessment scales utilized are variable; 12 (75%) reports employed a version of Montreal Cognitive Assessment or Information Questionnaire on Cognitive Decline in the Elderly. Lobar ICH was well identified, while non-lobar ICHs were variably grouped. Imaging markers have been reported in 10 (62.5%) reports. Though most studies report comorbidities and sociodemographic factors; stroke-specific severity / functional scales and genetic factors have only been considered by 2 (12.5%) articles each.

Conclusions:
At least 1 in 3 ICH survivors experience post-ICH CI over 12 months. There is an overall paucity of data on post-ICH CI, which highlights a critical need to characterize the natural history of post ICH CI in prospective cohorts and develop standardized assessment protocols for CI among ICH patients.