bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract W MP115: Clinical, Radiographic, and Outcome Characteristics of Patients with Intracerebral Cavernous Malformations and Seizures
Authors: Morparia Neha , Shin Cheolsu , Brown Robert D , Teresa Christianson , Flemming Kelly
Published: July 2021

Introduction:
Patients with intracerebral cavernous malformations (ICMs) may present with or later develop seizures. There are limited data regarding the clinical demographics of these patients, predictors of medically treatable versus medically refractory seizures, and long term seizure outcome.

Objective:
We aimed to characterize the clinical and radiographic features of supratentorial ICMs that present with seizures and describe their response to medical treatment.

Methods:
Patients with supratentorial ICMs were identified from a radiographic database for cases seen between 1989 and 1999. Clinical and radiographic information was abstracted and prospective follow up was obtained. Medically refractory seizures were defined as patients who were not seizure-free at last follow up, or who underwent surgery for refractory seizures.

Results:
A total of 206 patients were identified with a radiographic diagnosis of supratentorial ICM, 103 (50%) of whom presented with seizures and 7 (3%) who later developed seizures. Compared to those with seizures, patients without seizures were more likely to have a subcortical supratentorial ICM and to be on an antithrombotic agent. Intracerebral hemorrhage (ICH) at diagnosis did not predict presentation with seizure at diagnosis. Among the 59 patients treated with antiepileptics only, 16 (27%) were seizure-free at last follow up, 7 of whom no longer required medication and 8 of whom were controlled on a single agent. In the remainder of patients who were not seizure-free, seizure frequency was reduced in 37%, unchanged in 12%, increased in 5%, and unknown in 19%. Of the total 110 patients with seizures, 46 (42%) underwent at least one surgical removal of an ICM for medically refractory seizures.

Conclusions:
To date this study is one of the largest cohorts of ICM patients with seizures. Seizure is a common presentation in patients with cortical supratentorial ICMs. The presence of ICH at ICM diagnosis is not related to an increased occurrence of seizures at presentation. One-fourth of patients treated with antiepileptics alone eventually become seizure-free, almost half of which do not require medication at follow-up, suggesting that some non-surgical patients may not require life-long antiepileptic therapy.
Abstract W MP12: Changing Policies for Blood Pressure Management in Spontaneous Intracerebral Hemorrhage
Authors: Slater Jill , Morhaim Holly , Rudolph Steven
Published: July 2021

Background:
Current American Heart Association guidelines for targeted blood pressure management in spontaneous intracerebral hemorrhage (ICH), published in 2010, suggest a target mean arterial pressure of less than 110 or a blood pressure of less than 160/90 in patients without elevated intracranial pressure. These guidelines acknowledge that these recommendations have been based on incomplete efficacy evidence. A lower level recommendation was given for reducing target blood pressure to a systolic of 140, based on the INTERACT trial published in 2008. The INTERACT2 trial, published in May 2013, has been interpreted to establish the safety of rapid blood pressure lowering to 140 systolic.

Purpose:
To determine the current level of adoption by stroke centers of lower targets for blood pressure in patients with spontaneous intracerebral hemorrhage, and whether these targets have changed in 2013.

Methods:
We developed a web-based survey that was distributed via email and professional groups to stroke advanced practice nurses and stroke program coordinators. The survey asked specific questions regarding changes in clinical practice and stroke center policies on blood pressure management in spontaneous ICH. The survey was anonymous, and the survey software was able to exclude multiple entries from the same computer.

Results:
Responses were obtained from academic medical centers, community teaching hospitals, and community non-teaching hospitals. Awareness of the results of INTERACT2 was known by 65%, 50%, and 31% of stroke nurses at these hospitals, respectively. Targets for systolic blood pressure were changed in 2013 at 46%, 44%, and 11% of hospitals by group. A time target to lower blood pressure of less than one hour was adopted by 57%, 46%, and 28% respectively.

Conclusion:
Stroke centers have rapidly adopted changes in blood pressure management in intracerebral hemorrhage in advance of guideline revisions. Non-teaching hospitals were less likely to adopt these changes.
Abstract W MP13: Missed Imaging Diagnosis Without CT Perfusion May Affect Clinical Decision for TPA and Thrombectomy in Acute Stroke
Authors: Meng Sarah W , Liu Xiang , Hewitt Michael
Published: July 2021

Purpose:
In a previous study, we found higher detection rate of 2nd and 3rd order vascular thrombosis when CT Perfusion (CTP) was performed as compared to non-contrast CT (NCCT) and CT angiography (CTA) alone. Additionally, a significant number of patients with acute infarct were reported as negative without CTP. In this study, we sought to determine whether missed imaging diagnosis without CTP might affect clinical decision making.

Methods:
A total of 758 cases were included in our previous study, with CTP deficits reported in all 71 cases with final infarct volume of 2.8 ml or above. Conversely, 23 of 96 (24%) cases without CTP were reported as negative. In the group without CTP, 7 of 10 patients who had 2nd or 3rd order vascular thromboses with a final infarct > 30cc were reported negative, whereas only 1 of 10 cases were missed in patients who had CTP but a negative NCCT. The treatment decisions at the time of stroke were reviewed for these patients.

Results:
In 10 cases with final infarct volume > 30ml reported negative without CTP, zero received TPA or thrombectomy. Conversely, in the same category, 5 of 10 cases with positive CTP received TPA (p = 0.041). There was also a higher rate of TPA or thrombectomy treatment in patients with a positive imaging diagnosis, both with CTP (13 of 71, 18.3%) and without CTP (28 of 73, 38.4%), as compared to the group reported negative without CTP (3 of 23, 13%, p = 0.059). Fewer cases in the CTP group received treatment as compared to cases reported positive without CTP. A possible reason is that the cases with CTP were from an earlier phase of our acute stroke program, when treatment tended to be more conservative.

Conclusions:
Our study finds discrepancies in decision making for TPA and thrombectomy in stroke cases with positive versus negative imaging diagnosis. The cases reported negative were less likely to receive treatment, including those with relatively large final infarct size (>30ml). We speculate that a negative imaging diagnosis may create doubt for clinical diagnosis in some cases. Adding CTP in the acute stroke imaging protocol will increase imaging diagnostic accuracy and exclude stroke mimics, therefore providing valuable information for treatment.
Abstract W MP30: Safety of Unfractionated Heparin for Venous Thromboembolism Prophylaxis in Patients With Aneurysmal Subarachnoid Hemorrhage
Authors: Manoel Airton L , Goffi Alberto , Turkel-Parrella David , McCredie Victoria , Ben-Israel David , Abrahamson Simon
Published: July 2021

Background:
Venous thrombo-embolism (VTE) is common in patients admitted to intensive care units. The incidence of VTE in patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) varies from 1.5 to 18%, depending on the series and the screening strategy. There is limited data addressing the role of chemical prophylaxis in the aSAH population. Our institutional guidelines suggest VTE prophylaxis with sequential compression pneumatic devices prior to securing a ruptured intracranial aneurysm. Unfractionated heparin (UFH) at a dose of 5,000 IU (SC every 12 h) is considered after the aneurysm has been secured for 24 hours.

Methods:
We retrospectively reviewed data from all aSAH patients admitted to a 19-bed high volume aSAH ICU, between January 2013 and June 2013.

Results:
Fifty-two patients with aSAH (mean age 58.6, range 28-93) were admitted during the study period. In total, 61 aneurysms were found, 46 ruptured, and additional 10 incidentally discovered aneurysm. 72.1% of aSAH patients received UFH after aneurysm treatment. In the 26.9% of patients UFH was withheld; these patients had either unsecured aneurysms or withdrawal of life-sustaining treatments. Of the patients who received UFH 48.7% received the medication at 24h after aneurysm treatment, 33.5% within 72h; and in 15.4% heparin was started beyond 72h after aneurysm treatment. The mean time from aneurysm treatment to initiation of VTE prophylaxis was 2.1 days. Of those patients who received UFH, 22 patients (58%) had an External Ventricular Drain. Endovascular treatment was the main modality as compared to surgical clipping (61.5 vs 15.4%). 6 patients (11.5%) received prophylactic dose of UFH and dual antiplatelets therapy (aspirin and clopidogrel). 1 patient (2%) who was on UFH had a major cerebral hemorrhagic complication and died, however, this patient was also on aspirin and clopidogrel. 8 patients (21%) were investigated for clinical suspicion of VTE; 1 patient (2%) on UFH had a pulmonary embolism.

Conclusion:
The use of subcutaneous UFH for VTE prophylaxis after 24h of aneurysm treatment is feasible, safe, and effective in an aSAH population. Caution should be taken in patients receiving subcutaneous UFH and antiplatelet agents, in whom the risk of intra-cerebral bleeding is higher.
Abstract W MP35: Localized Increase of Myeloperoxidase in the Lumen of Human Cerebral Aneurysms
Authors: Hasan David M , Chu Yi , Nauseef William M , Pierce Gary L , Cheng Guangjie , Wegman-Points Lauren , Pena Silva Ricardo A , Heistad Donald D
Published: July 2021

The neutrophil granule protein myeloperoxidase (MPO) reacts with H
2
O
2
to oxidize chloride, thereby generating hypochlorous acid (HOCl), a highly reactive product. Circulating levels of MPO are increased in many inflammatory diseases, and have been linked to oxidative stress and elevated risk for vascular disease in humans. We hypothesized that MPO is
increased locally
in human intracranial aneurysms. Blood, both from the lumen of the aneurysm and femoral artery, and tissue, both from the aneurysm wall and from a superficial temporal artery, were sampled from seventeen patients with intracranial aneurysms who underwent microsurgical clipping. Plasma concentrations of MPO (ELISA) were 3-fold higher in aneurysm (100±15 ng/ml) (mean±SE) than in femoral blood (33±10; p=0.0007). Plasma concentrations of vascular peroxidase 1 (VPO1), a homologue of MPO that is expressed in endothelial cells, were not increased in aneurysm (384±51 μg/ml) compared to femoral blood (513±65; p=0.12). mRNA expression (RT-qPCR) was similar in leukocytes recovered from aneurysmal blood (2005±377 copies/50 ng RNA for MPO and 342±98 for VPO1) and femoral blood (2129±313 for MPO and 381±61 for VPO1; p=0.5 and 0.73, respectively). There were significantly more MPO-positive cells (immunohistochemistry) in aneurysm tissue (69±8 positive cells/field, 32%±3% of total cells) than superficial temporal artery (6±3 positive cells/field, 2%±1%; p<0.001). These findings suggest that MPO is increased specifically and locally in aneurysm blood and tissue, and the increase is contributed by MPO-positive cells in aneurysm tissue. We speculate that local MPO may contribute to the formation and/or rupture of intracranial aneurysms, and thus, could be a therapeutic target.
Abstract W MP38: Apolipoprotein A-I (ApoA-I) Mimetic Peptide, D-4F, Regulates miRNA Expression and Improves Functional Outcome after Stroke in Diabetic Rats
Authors: Ning Ruizhuo , Chopp Michael , Zacharek Alex , Yan Tao , Roberts Cynthia , Chen Jieli
Published: July 2021

Introduction:
Diabetes mellitus (DM) in patients is associated with low high-density lipoprotein cholesterol (HDL-C) and impairment of the anti-oxidative capacity of HDL-C. Several miRNAs have been identified as having a physiological role in tissues in which diabetes complications occur. D-4F is an economical ApoA-I mimetic peptide which increases HDL function. We therefore investigated the therapeutic effect and underlying mechanisms of D-4F treatment of stroke induced functional benefit effects in type one DM (T1DM) rats.

Methods:
T1DM was induced in Wistar rats by streptozotocin (60mg/kg, ip) .Subsequently they were subjected to embolic middle cerebral artery occlusion. D-4F (10 mg/kg i.p.) was administered at 2h, 24h and 48h after stroke. Functional outcomes, brain blood barrier (BBB) leakage and lesion volume were evaluated.

Results:
D-4F treatment of stroke in T1DM rats significantly decreased Evans Blue dye leakage (15.85±1.52 ng/mg vs contro: 30.57± 5.88 ng/mg) and significantly improved functional outcome compared to non-treatment T1DM-control. D-4F treatment significantly increased miR-124a and miR-181c, but decreased miR-200b expression in the ischemic brain. Using laser capture, D-4F also significantly increased ischemic brain endothelial cell miR-126 expression compared to non-treatment control. In addition, D-4F treatment significantly decreased miR-181c target gene tumor necrosis factor-a (TNF-a), and miR-124a target gene monocyte chemoattractant protein-1 (MCP1) expression. D-4F also decreased proinflammatory nuclear NFkB (26.07±3.17 vs 37.43±3.47), Toll-like receptor 4 (TLR4, 7.26±0.69 vs 10.5±1.2), matrix metalloproteinase 9 (MMP9, 0.16±0.04 vs 0.48±0.09) expression, and increased CD163 (M2 macrophage marker, 120.98±8.13 vs 85.02± 9.47) number compared to T1DM-MCAo control rats.

Conclusion:
D-4F treatment of stroke in T1DM rats regulates miRNA expression and their target gene and protein expression and induces anti-inflammatory effects and promotes M2 macrophage polarization which may contribute to D-4F decreased BBB leakage and induced functional benefit effects after stroke in T1DM rats.
Abstract W MP94: Acute Inflammation Expands Cerebral Microbleeds in a Mouse Model of Cerebral Amyloid Angiopathy
Authors: Vasilevko Vitaly , Fisher Mark J , Kilday Kelley , Passos Giselle F , Liu Shuo , Kim Ronald C , Paganini-Hill Annlia , Cribbs David H
Published: July 2021

Introduction:
Cerebral microscopic hemorrhages are the pathologic substrate of cerebral microbleeds (CMB). Little is known about mechanisms of expansion of CMB. Here we studied the dynamics of CMB after acute inflammation, using a transgenic mouse model of cerebral amyloid angiopathy with spontaneous microscopic hemorrhages and endotoxin (lipopolysaccharide, LPS) as an inflammatory stimulus.

Methods:
21-month old Tg2576 mice and wildtype littermates received a single dose of LPS, 100 or 1000 ug/kg i.p., or phosphate-buffered saline (PBS) as control. Mice were sacrificed 48 hours later and brains were collected for the analysis of microscopic hemorrhages, as well as edema formation, blood-brain barrier constituents and glial activation. Differences among groups were tested by anova and contrasts.

Results:
Hematoxylin and eosin staining demonstrated no freshly-formed microscopic hemorrhages in LPS-treated mice. Using Prussian blue staining, we found that total area, average size, and number of CMB differed significantly between PBS-treated wildtype and transgenic mice (p=0.03, p=.04 and p=.03 respectively). Acute inflammation did not significantly affect total area, average size, or number of CMB in wildtype animals. For transgenic mice, both doses of LPS significantly (p<.01) increased the total area of Prussian blue-positive lesions (2.2 to 2.9-fold increase), and higher LPS dose significantly (p<.01) increased average size of CMB by 2.6-fold; both average and total size of CMB increased in a dose-dependent manner. IgG and fibrinogen levels significantly increased after high dose LPS injection in both wildtype and transgenic mice (p<.05). Tight junction protein claudin-5 levels were also increased in high dose LPS-treated mice (p<0.05). LPS injection significantly increased expression of activated microglia markers CD45, CD14, and Iba1.

Conclusions:
In a mouse model of cerebral amyloid angiopathy, acute inflammatory stimulus induced expansion of CMB without producing fresh hemorrhage. Increased size of CMB was associated with indices of cerebral edema, alteration of tight junction constituents, and microglial activation. These findings suggest that cerebral edema may mediate expansion of cerebral microbleeds.
Abstract W P163: Could CT Angiogram be the Next Screening Test for Carotid Disease? Ultralow Radiation for Neck CT Angiography
Authors: Lira Diego A , Gonzalez Ramon G , Kalra Mannudeep K , Singh Sarabjeet , Romero Javier M
Published: July 2021

Introduction:
CTA is a high resolution technique, used to confirm carotid and vertebral artery stenosis suspected on carotid ultrasound or MRA. However, this technique rightfully so has not been used as a screening technique given concerns regarding radiation dose, particularly on young patients and repeat examinations, with special consideration of anatomic proximity to the thyroid, a radiosensitive organ. Our objective is to significantly reduce the effective radiation dose of this exam, without reducing diagnostic accuracy.

Methodology:
A new reduced radiation dose scanning protocol for neck CTA (100 Kv, 140 Ma, pitch 0.5, rot time 0.5 sec) was developed at our institution and applied on 10 patients who underwent the exam with indication of vascular disease. The exams were reviewed by 2 staff radiologists who assessed image quality and diagnostic accuracy, both on standard thin slice (0.625 mm) images, orthogonal views and dedicated high resolution individual vessel reconstructions. Total radiation doses were obtained, and compared against the standard of care protocol (120 Kv, 235 Ma, pitch 0.5, rot time 0.5 sec).

Results:
Compared to standard of care imaging protocol we achieved a 62% reduction of radiation dose, from a CTDI of 42 mGy to 16 mGy and an estimated dose for thyroid gland from 14.2 mSv to 5.1 mSv. All 10 exams were considered of diagnostic quality. Image resolution for neck soft tissues was not affected.

Conclusion:
The number of neck CTA exams are rising in the last decade. Efforts must be made in order to keep radiation doses to the minimum possible without compromising image quality. This new low dose protocol enables full diagnostic capabilities of vascular disease with significant dose reduction. Although this dose is not low enough for a viable screening test, there is potential for further reduction, which can be researched and applied in future studies.
Abstract W P18: General Anesthesia is Associated With Reduced Likelihood of Good Functional Outcome After Endovascular Intervention for Acute Ischemic Stroke
Authors: Mlynash Michael , Fields Jeremy D , Straka Matus , Bammer Roland , Kemp Stephanie , Marks Michael P , Albers Gregory W , Lansberg Maarten G
Published: July 2021

Background:
Retrospective studies have suggested that the use of general anesthesia (GA) is associated with unfavorable outcomes in patients undergoing endovascular intervention for acute ischemic strokes. We aimed to assess this association in DEFUSE 2, a prospective cohort study of patients treated with endovascular therapy.

Methods:
In the DEFUSE 2 study, MRI was performed before, within 12 hours after, and 5 days after endovascular intervention. Good functional outcome was defined as mRS 0-2 at 90 days. All patients who underwent catheter angiography were included in the present analysis. Baseline characteristics and outcomes were compared between patients managed with general anesthesia (GA) vs. conscious sedation (CS). Variables that were associated with good functional outcome in univariate analyses (α<0.1) were entered into a multivariable analysis. Variables that were significant at α<0.05 after a backward elimination procedure were retained.

Results:
GA was utilized in 39/110 patients (35%) and CS in the remainder. Compared to the group managed with CS, those undergoing GA were older (70±13 vs. 63±17 years old), had higher SBP (156±29 vs. 144±21 mmHg), higher blood glucose levels (149±64 vs. 126±35 mg/dL), and higher NIHSS (median [IQR]: 18 [14-21] vs. 14 [9-19]). The GA group was more likely to have had a previous stroke or TIA (36% vs. 17%) and prior treatment with antiplatelet agents (46% vs. 26%). Rates of reperfusion were similar (49% vs. 65%, p=0.15) between patients managed with GA and CS. Patients managed with GA had a substantially lower rate of good functional outcome (21% vs. 55%, p=0.001). Age, DWI lesion volume, reperfusion status and GA were retained in the multivariable model as independent predictors of good functional outcome. The adjusted odds ratio for good functional outcome with GA was 0.21 (95% CI 0.07 - 0.66).

Conclusion: In general,
GA should be avoided in patients undergoing endovascular treatment for acute ischemic stroke as it is associated with worse clinical outcomes. The mechanisms underlying this association should be investigated.
Abstract W P189: Characteristics of Rural Pre-Hospital Stroke Transports
Authors: Whiteman Charles , Paulson Debra , Sikora Rosanna , Doerr Russell , Davis Stephen , Davidov Danielle
Published: July 2021

Introduction:
West Virginia (WV) is the second most rural state and has a stroke prevalence of 3%. According to the United States Census Bureau, 97.3% of the land is considered rural and 51.3% of the population lives in a rural area. EMS transport times in Northern WV often exceed 20 minutes in rural counties. Little data has been published about EMS response to acute stroke patients in the rural setting.

Methods:
This was a retrospective cohort study of EMS response and interventions for patients with chief complaint of stroke in the MedCom database providing medical command for 26 northern WV counties. Stroke encounters from January 1, 2002 to December 31, 2011 were analyzed for EMS provider capability, receiving hospital capability, and pre-hospital interventions.

Results:
There were 7,594 transports available for analysis. Basic Life Support (BLS) responders provided 7.0% of the care. The majority of the patients, 51.6%, were transported to an acute care hospital, 11.6% to a critical access hospital, and 36.9% to a designated stroke center. Blood glucose was determined by glucometer in 66.4% of patients with 2.0% treated for hypoglycemia. Vascular access was attempted in 92.6% of the patients and was successful in 81.5%. Cardiac monitor was applied in 92.4% of the patients and oxygen saturation was determined by pulse oximetry in 95.8%. Oxygen therapy was administered to 96.5% of the patients.

Discussion:
In rural northern WV, 7% of the suspected stroke patients had care by only a BLS responder. Although evaluation at a designated stroke center has been shown to increase the chance for receiving acute thrombolytic intervention, less than 40% of patients in northern WV were initially seen at a designated stroke center and 11.6% were initially seen at a critical access hospital. Consequently, even critical access hospitals need to be prepared to rapidly evaluate and treat patients with suspected ischemic stroke. Blood glucose was not checked by EMS personnel in more than 30% of all transports. Additional studies are needed to assess the impact of these pre-hospital procedures and transport destination decisions on suspected stroke patient outcomes in the rural setting.
Abstract W P194: Telestroke is Not Associated With a Lower Rate of IV Thrombolysis
Authors: Shafi Neelofer , Hoelzel Sandra , Grysiewicz Rebbeca , Khaja Aslam , Testai Fernando D
Published: July 2021

Background:
Telestroke is an increasingly used mode of assessment of acute stroke patients when vascular neurologists are not available onsite. We provided onsite stroke hospitalist services at a local community hospital via onsite, bedside assessment for 18 months. Coverage was then transitioned to telestroke only assessment, at the same hospital with the same vascular neurologists. We sought to determine if IV r-tPA rates changed.

Methods:
Onsite coverage was from April 2011 through September 2012 (Group 1). Telestroke only coverage was from October 2012 through July 2013 (Group 2). We reviewed all acute stroke codes and determined which patients were treated with IV r-tPA. We also collected door to needle (DTN) times. Fisher’s exact and independent t-tests were used where appropriate.

Results:
In Group 1 there were 578 acute stroke codes. 52 of these patients (8.9%) received IV r-tPA. Group 2 had 356 acute stroke codes, 29 of which received IV r-tPA (8.1%). This difference was not statistically significant (p=0.7201). Mean number of patients treated with IV r-tPA per month was 2.8 for Group 1 and 2.9 for Group 2. Mean DTN time was 76.73 min for Group 1 and 90.63 min for Group 2. This shows a trend toward shorter DTN times with bedside assessment but this difference is not statistically significant (p=0.0798).

Conclusion:
IV r-tPA administration rates do not fall when a telestroke only coverage model replaces an onsite model. This suggests that telestroke coverage is sufficient to maintain IV r-tPA treatment rates, even when vascular neurologists are not available at the bedside.
Abstract W P196: Post-Stroke Activation of Angiotensin Converting Enzyme 2 is Neuroprotective
Authors: Bennion Douglas M , Haltigan Emily , Irwin Alexander , Lauren Donnangelo , Pioquinto David , Sumners Colin
Published: July 2021

Background:
Recent discoveries point to the angiotensin converting enzyme 2/angiotensin-(1-7)/mas (ACE2-Ang-(1-7)-Mas) axis as a potential target for neuroprotective stroke therapies. Central pre-stroke activation of this axis by infusion of diminazene aceturate (DIZE), an activator of ACE2, improves stroke outcomes in rats. This led us to hypothesize that intraperitoneal (IP) post-stroke injections of DIZE may exert similar Mas-mediated neuroprotection and thus offer additional clinically-relevant evidence to support this approach. We also assessed the direct effects of DIZE on ACE2 activity in brain tissue.

Methods:
Male SD rats underwent ischemic stroke by endothelin-1-induced middle cerebral artery occlusion and were randomly divided into groups (n=~12/group) that received IP injections of dH2O or DIZE (0.75, 2.5, or 7.5 mg/kg) at 4, 24, and 48 h after stroke, as well as blinded neurological assessments at 4, 24, and 72 h after stroke. Additional groups received pre- and post-stroke intracerebroventricular (ICV) infusion of sterile 0.9% saline or Mas receptor antagonist A-779 in addition to post-stroke control or drug therapy. Immediately after the 72 h tests, animals were euthanized, cerebral infarct size assessed by TTC staining, and tissue harvested for ACE2 activity assay. Data are expressed as mean ± SEM with significance inferred at p<0.05.

Results:
Mean infarct sizes (%) were significantly decreased by post-stroke IP injections of all doses of DIZE (0.75 mg/kg: 29.9±5.0; 2.5 mg/kg: 27.9±4.2; 7.5 mg/kg: 31.36±4.1) vs. dH2O (41.9±3.8). At 24 h post-stroke, neurologic deficits (Garcia and Bederson scales) were significantly improved in DIZE-treated rats (7.5 mg/kg: 16.7±0.2 and 0.5±0.1) vs. controls (15.5±0.4 and 1.1±0.2). ICV infusion of A-779 in DIZE-treated rats abolished the improvement in infarct size observed in saline infused DIZE-treated rats (A-779: 43.8%±7.5; saline: 25.8±6.7). Addition of DIZE (4 nmol/μg protein) to brain homogenate increased ACE2 activity by more than 3-fold.

Conclusions:
This suggests that targeting the ACE2/Ang-(1-7)/Mas axis by post-stroke DIZE injections exerts neuroprotection in a Mas-dependent fashion.
Abstract W P2: Intra-arterial Contrasted Cone-beam CT Assessment of Occluded Distal Vessels in Acute Ischemic Stroke Patients with Major Vessel Occlusion
Authors: Amano Tatsuo , Sato Masayuki , Mori Kentaro , Matsumaru Yuji , Hamada Yusuke
Published: July 2021

Background and Purpose:
Identifying the information of occluded distal vessels is quite important for making a suitable selection of treatment strategy and devices in endovascular revascularization therapy (EVT) for acute ischemic stroke patients. It has been demonstrated that intra-venous cone-beam CT (IV-CBCT) is able to visualize distally of the occluded vessels. In this study, intra-arterial contrasted high-resolution cone-beam CT from ascending aorta (Ao-CBCT) was newly introduced for the visualization of occluded distal vessels and its clinical values were assessed

Methods:
Acute ischemic stroke patients with major vessel occlusion planed EVT were evaluated. Adaption of EVT was decided by using MRI/MRA assessment in advance. In endovascular procedure, digital subtraction angiography (DSA) and Ao-CBCT were performed to evaluate occluded site, collaterals and occluded distal vessels with local anesthesia. Ao-CBCT images were acquired in 20 seconds rotational scan. Contrast medium was injected from ascending aorta with 1mL/s for a total of 30 seconds by use of a 4F or 6F catheter and an imaging delay of 10 seconds. We assessed the image quality of Ao-CBCT and compared in the visualization of occluded distal vessels among MRA, DSA and Ao-CBCT.

Results:
We analyzed 14 patients (mean age, 66 years. 3 female patients), respectively. Stroke subtypes were cardiogenic (n=6), atherothrombotic (n=5) and others/unknown (n=3). Occluded site were MCA M1 (n=8), MCA M2 (n=2), ICA (n=2), MCA M4 (n=1) and BA (n=1). All obtained Ao-CBCT images could evaluate occlusion distal vessels successfully and 11 images (79%) were excellent. In all cases, Ao-CBCT images could depict occluded distal vessels more detailed than MRA and DSA.

Conclusions:
Ao-CBCT is an efficient method to obtain the detailed information of occluded vessels compared with conventional examination methods. It requires less contrast agent compared to IV-CBCT, while maintaining enough information to determine treatment strategy.
Abstract W P201: Angiopoietin-1 Mimetic Peptide Treatment of Stroke Regulates MicroRNA Expression and Promotes Neuroprotection in Type One Diabetic Rats
Authors: Zacharek Alex , Chopp Michael , Ning Ruizhuo , Yan Tao , Van Slyke Paul , Dumont Daniel , Roberts Cynthia , Chen Jieli
Published: July 2021

Introduction:
Angiopoietin-1 (Ang-1) mediates vascular remodeling. Diabetes decreases Ang1 and disrupts Ang1/Tie2 signaling, impairs vascular maturation and regulates immune response. MicroRNAs have been implicated in vascular diseases and inflammation. Vasculotide (VT) is an Ang1 mimetic peptide that promotes Tie2 activity. We hypothesize that treating type one diabetic rats (T1DM) with VT after stroke regulates miRNA expression decreases pro-inflammatory factors and thereby produces a neuroprotective effect.

Methods:
T1DM was induced in male Wistar rats with streptozotocin followed by 2h transient middle cerebral artery occlusion (MCAo). These rats were then treated with: 1) PBS control; 2) VT (3 ug/kg, ip injection) just prior to stroke and at 8h and 24h after MCAo. Functional tests were conducted 48h after MCAo. Afterwards, brain hemorrhage, BBB leakage, miRNA expression, RT-PCR, immunostaining and Western blot assays were done.

Results:
VT treatment did not decrease brain hemorrhage, but significantly decreased Evans Blue leakage (30.6±5.8 ng/mg vs. 17.9±2.0 ng/mg) lesion volume (35.1±3.5% vs 25.8±5.3%) and improved functional outcome after stroke when compared to control (p<0.05). To elucidate the mechanism, miRNA was measured. VT treatment significantly increased miR-451 (81.6 folds), miR-155 (2.4 fold), miR-98 (1.9 fold), and miR-126 (1.5 fold) expression, but decreased miR-200b (3.8 fold). Immunostaining showed that VT significantly decreased the number of apoptotic (45.5±3.7 vs 30.8±2.6) and cleaved-caspase-3 positive cells (45.2±3.5 vs 33.1±4.3), as well as monocyte chemotactic protein-1 (MCP1, 5.02±0.4% vs 1.8±0.2%) and tumor necrosis factor (TNF)-alpha (3.1±0.5% vs 1.5±0.2%). Western blot showed that VT significantly decreased receptor for advanced glycation end products (RAGE), MCP1 and TNFa (3-5 fold) in the ischemic border area compared to T1DM control.

Conclusion:
VT promotes neuroprotection after stroke in T1DM rats. Regulation of miRNA and neuroinflammatory factor expression and decreased BBB leakage may contribute to the VT induced neuroprotective effects observed after stroke in T1DM rats.
Abstract W P206: Analysis of SUMO3-Modified Proteome in Post-Ischemic Mouse Brain
Authors: Yang Wei , Sheng Huaxin , Thompson Will , Zhao Shengli , Wang Liangli , Liu Xiaozhi , Paschen Wulf
Published: July 2021

Background and Purpose:
Small ubiquitin-like modifier (SUMO) conjugation modulates many key cellular processes. Transient cerebral ischemia dramatically activates SUMO2/3 conjugation, and this is believed to be a protective stress response. It is, therefore, of tremendous clinical interest to characterize the SUMO-modified proteome regulated by transient ischemia. We generated a novel SUMO transgenic mouse and performed the first SUMO proteomics study using post-ischemic brain samples.

Methods:
CAG-loxP-STOP-loxP-SUMO (CAG-SUMO) mice were generated in which His-SUMO1, HA-SUMO2, and FLAG-SUMO3 were expressed from a single multicistronic transgene in a Cre-dependent manner. CAG-SUMO mice were mated with Emx1
Cre/Cre
mice to generate double transgenic CAG-SUMO/Emx1-Cre mice as experimental mice and Emx1
Cre/+
mice as control mice. Double transgenic mice were subjected to 10 min global cerebral ischemia followed by 1 h reperfusion or sham operation. FLAG-SUMO3-conjugated proteins were enriched from cortical tissues and analyzed.

Results:
Characterization of double transgenic mice demonstrated that exogenous expressed tagged SUMO paralogues were functionally intact and did not perturb the endogenous SUMOylation machinery in the brain. FLAG pulldown of cortical samples from sham and ischemia mice followed by GeLC-MS/MS analysis identified 91 candidates whose SUMOylation states were up-regulated in ischemic samples. Data analysis revealed several potentially important processes in which SUMO3 conjugation may play a key role during ischemia/reperfusion, including the cross-talk between SUMOylation and ubiquitination, glucocorticoid receptor signaling, and modulation of posttranscriptional mRNA processing.

Conclusions:
SUMO proteomic analysis identified important processes and pathways modulated by SUMOylation in the post-ischemic brain that warrant future investigations, since they could be the key to understand the overall impact of SUMOylation on the fate and functions of post-ischemic neurons. The conditional SUMO transgenic mouse will be an invaluable tool for in-depth in vivo analysis of the SUMO-modified proteome in various pathological states.
Abstract W P223: Treatment of Cervical Artery Dissection with Different Antithrombotic Agents
Authors: Caprio Fan Z , Bergman Deborah , Curran Yvonne , Bernstein Richard , Prabhakaran Shyam
Published: July 2021

Background and Purpose:
Antiplatelet agents and anticoagulants are both accepted and commonly used agents for treatment of cervical artery dissection (CAD), though randomized clinical trials are lacking. We report on the use of novel oral anticoagulants for CAD and compared their efficacy and safety to traditional anticoagulants.

Methods:
We retrospectively identified patients diagnosed with CAD at a single academic center between July 2010 and December 2012. Patients treated with novel anticoagulants (NOAC: dabigatran or rivaroxaban), other anticoagulants (AC: warfarin, heparin, or low molecular weight heparin), or antiplatelet agents (AP: aspirin, clopidogrel, or aspirin-dypyridamole) were compared for baseline characteristics, recurrent stroke, vessel recanalization on follow-up, and bleeding complications using Fisher’s exact and student t-tests.

Results:
During the study period, 110 patients with CAD were included, of whom 20 (18%), 61 (55%), and 29 (26%) were treated initially with a NOAC, AC, and AP, respectively. Clinical follow-up was available in 98 (89.1%) patients while radiographic follow-up was available in 88 (80%) patients. NOAC-treated patients were more likely to have presented with ischemic stroke symptoms (90% vs. 55.7%, p=0.007) but had similar rates of severe stenosis (60% vs. 53.3%, p=0.522) and intraluminal/intramural thrombus (70% vs. 57.6%, p=0.327) on initial vascular imaging compared to AC patients. There was 1 recurrent stroke in the NOAC group and 1 in the AC group. Similar proportions of patients had resolved or improved stenosis on follow-up imaging (NOAC: 66.7 vs. AC: 63.3%, p=0.217). Hemorrhagic complications were more likely to occur in AC compared to NOAC patients (17.0% vs. 0%, p=0.019).

Conclusion:
In this retrospective study, use of novel oral anticoagulants for CAD was associated with similar rates of recurrent stroke and vessel recanalization on follow-up imaging but with fewer hemorrhagic complications. Given their safety profile, NOACs may be a reasonable alternative to traditional anticoagulants in CAD. Prospective validation of these findings is needed.
Abstract W P230: A Simple Prediction Score for Hospital-Acquired Infections in Acute Ischemic Stroke
Authors: Friedant Adam , Gouse Brittany , Boehme Amelia K , Siegler James E , Albright Karen C , Monlezun Dominique , George Alexander , Beasley T. Mark , Martin-Schild Sheryl
Published: July 2021

Background:
Hospital-acquired infections (HAI) are a major cause of morbidity and mortality in acute ischemic stroke (AIS) patients. While prior scoring systems have been developed to predict pneumonia (PNA) in AIS patients, these scores were not designed to predict other infections that complicate hospital stays. We sought to develop a simple scoring system for any HAI.

Methods:
Patients admitted to our stroke center (07/08-06/12) were retrospectively assessed. Patients were excluded if they had an in-hospital stroke, unknown time from symptom onset, or delay from symptom onset to hospital arrival >48 hours. Infections were diagnosed via clinical, laboratory and imaging methods using standards set forth by our center. A scoring system was created to predict infections based on patient characteristics available at the time of admission.

Results:
Of the 568 people who met inclusion criteria, 84 (14.8%) developed an infection during their inpatient stay. Patients who developed infection were older (73 vs. 64, p<0.0001), were more frequently diabetic (43.9% vs. 29.1%, p=0.0077), and had more severe strokes on admission (NIHSS 12 vs. 5, p15 5 points). Patients with an infection score of >4 were at 5 times greater odds of developing an infection (OR 5.67, 95% CI 3.28-9.81, p<0.0001). The area under the curve for this score showed fair sensitivity and specificity for predicting HAI after AIS (AUC=0.7311).

Conclusion:
In our sample of AIS patients, clinical and laboratory characteristics available on presentation identified patients at risk for infections during their acute hospitalizations. Validation is required in other populations. If validated, this score could assist providers in predicting and preventing infections after hospitalization for AIS.
Abstract W P245: Process Improvement to Reduce Time Interval From Hospital Arrival to Intravenous Thrombolysis in Acute Stroke
Authors: Kim Eun Hye , Lee Kijung , Song Dongbeom , Kim Young Dae , Cho Han-Jin , Lee Kyung Yul , Nam Hyo Suk , Heo Ji Hoe
Published: July 2021

Background:
Rapid administration of intravenous recombinant tissue plasminogen (rt-PA) is an effective way to enhance thrombolytic efficacy in stroke patients. We had already shown that a stroke code program based on the computerized physician order entry system could reduce time interval from hospital arrival to IV thrombolysis. We investigated that process improvement, which is an activity to improve existing process by making changes, could further reduce in-hospital time delay in thrombolytic therapy.

Methods:
During the first period (Jan. 2007 - Dec. 2009), we set the target time from emergency department (ED) arrival to IV thrombolysis at 40 minutes, monitored time intervals to evaluations and treatment at weekly stroke conference and determined the possible factors that were associated with time delay in cases who did not receive IV thrombolysis within 40 minutes. During the second period (Jan. 2010 - Dec. 2012), after review of factors of time delay during the first period, we implemented a tool for explanation to patients and their families, which included a standardized script and a Visual Decision Aid for tPA treatment (developed by UCLA stroke center).

Results:
After setting the target time and continuous monitoring of the process, median time from ED arrival to IV thrombolysis was reduced from 63 min to 45 min (p<0.001). During the first period, the most common cause of the time delay was delayed decision of family (15.9%). After implementation of the standardized patient explanation tool, the proportion of the time delay due to the delayed decision was significantly reduced from 15.9% to 3.3% (p=0.005), which resulted in further reduction of time interval from ED arrival to IV thrombolysis to 43 min (p=0.001).

Conclusion:
Continuous process improvement activity was effective in reduction of time intervals from ED arrival to IV thrombolysis in acute stroke patients. Setting target time with continuous monitoring of the performance and a standardized explanation for patients and their families using a script and a Visual Decision Aid were helpful to improve stroke team performance and reduction of time delays.
Abstract W P274: Developmental Evaluation Enhances Utility of the Toronto Stroke Networks Virtual Community of Practice
Authors: Fortin Joanne , Skryabka Krystyna , Avinoam Gail , Sharp Shelley , Willems Jacqueline , Linkewich Elizabeth
Published: July 2021

Background:
The Toronto Stroke Networks (TSNs) Virtual Community of Practice (VCoP) was developed to connect stroke healthcare providers (HCPs), enhance professional and organizational stroke expertise, foster implementation of best practices, and improve patient outcomes in stroke care. The VCoP is a secure social media platform fostering cross system interprofessional collaboration (IPC).

Purpose:
To use formative developmental evaluation to inform further improvement of the VCoP’s content and performance and to measure its efficacy as a KT tool to support IPC.

Methods:
An evaluation framework was developed based on “Promoting and assessing value creation in communities and networks” (Wengar, 2011). Stroke HCPs from 15 organizations in the TSNs were provided VCoP training to build virtual competence and to seek feedback for enhanced utility. The TSNs Education and KT Implementation Plan for 2013-2014 integrated activities that encourage VCoP use. These activities include co-development of educational material across sites, information sharing between meetings, and to support implementation of specific activities. Qualitative (e.g. value stories, narratives) and quantitative indicators (e.g. membership and usage) data are evaluated.

Results:
The TSNs VCoP currently has: 287 members and 26 groups (open and private groups with 4-19 members). There are 8 interprofessional discussions, with a total of 20 pre-populated and requested forums. Feedback from the membership has prompted investments to improve search features and identification of members within the site for more efficient collaborations. Uploading of Provincial Stroke Rounds, provision of a Research and Knowledge Translation Widget, and securing a space for HCPs to submit recommended presentations were added to increase the value-add of the site as a one-stop shop for Stroke HCPs seeking stroke care information. Qualitative analysis of value stories demonstrating the efficacy of the VCoP for IPC is in progress and will be available at time of publishing.

Conclusions:
The VCoP is an innovative approach to enhancing the system of stroke care. This formative developmental evaluation approach has enhanced the utility of the VCoP as a source for stroke information and HCP connections.
Abstract W P283: The Challenges and Opportunities for Improving Transitions of Care: University Hospitals Case Medical Center Comprehensive Stroke Center Experience
Authors: Vickers Kathleen , Shams Tanzila , Fussner Julie , Sila Cathy
Published: July 2021

Background:
Stroke Prevention Clinics were established in 2009 with the expectation that all stroke patients would follow up at 30 days after discharge to review their plan of care.

Purpose:
We sought to determine the barriers to meeting our goals.

Methods:
All UHCMC hospital discharges for TIA/ ischemic stroke from 2/1/10-5/31/10 (wave 1) and 12/1/12-3/31/13 (wave 2) were reviewed and data collected on post-discharge ambulatory visits, patient demographics, insurance and provider status, discharge disposition, appointments scheduled prior to discharge, and patient responses to personal telephone reminders prior to their follow up visit.

Results:

In Wave 1, significant (p< .05) vulnerability factors for patients “No Show” to follow up included discharge to a facility but systems issues played a greater role for those who were older, male, and African-American. These factors persisted in Wave 2 and also included lack of a prior PCP (40% vs 12%). Systems issues included discharge without a confirmed follow up appointment and inaccurate contact information to confirm or reschedule appointments.

Conclusions:
Despite Stroke Education sessions emphasizing the importance of follow up after discharge, 38-46% of patients had no documented stroke preventive care. Systems improvements implemented after Wave 1 were effective in reducing this gap from 25% to 12% in Wave 2 and included customizing the EMR Discharge Profile for Stroke with specific written messages, establishing a Care Coordinator to teach back with patients and families, and streamlining scheduling processes. However, patient factors are increasing and the expanded vulnerable population has increased disability and greater unmet needs. Focused interviews are being conducted to better understand these barriers to care.
Abstract W P290: Stroke Nurse Fellowship: Improving Quality and Coordination in Complex Stroke Patient Care
Authors: Banks, MS, RN Domonique , Yarbrough, MS, ACNP Karen , Ball, BSN, RN, CNRN Christine
Published: July 2021

Background:
Aligned with our Primary Stroke Center’s goal to achieve Comprehensive Stroke Center (CSC) designation, nursing leadership met to discuss strategies to increase bedside expertise following an influx of new graduate nurses. CSCs are required to operate inpatient stroke units staffed by qualified stoke caregivers, comply with professional standards, and demonstrate a commitment to providing stroke related education. Thus, a stroke nurse fellowship (SNF) program was developed. The SNF serves as an essential resource for nursing/patient education, performance improvement, and staff retention. The purpose of this abstract is to provide an overview of the SNF Program content, implementation, and feasibility.

Methods:
The SNF curriculum was developed from the American Board of Neuroscience Nursing’s new Stroke Certified Registered Nurse (SCRN) credentialing. The program reviews CSC standards/performance measures and provides interdisciplinary neurology rounding experiences, mock survey tracer exercises, rehab facility observation, and BAT code simulated learning. Program classes are 4 hours biweekly for 6 months and culminate with a mentored process improvement (PI) project. Potential applicants are recruited from the pool of less experienced nursing staff.

Results:
Nine candidates from 3 nursing units submitted applications. Seven were selected to begin the fellowship program in September, 2013. Program outcomes include percent of stroke related patient education standards documented, percent of candidates successful on SCRN examination, PI project impact, and increased nurse retention. Also, barriers and facilitators of the program will be reviewed.

Conclusion:
Developing a SNF program was feasible due to interdisciplinary collaboration and use of existing resources, thereby minimizing financial constraints. The SNF Program supports the UMMC’s commitment to the regulatory and educational standards of a CSC. There is potential for other specialty services to use this program as a model for developing unit based experts and improving the quality of patient care.