bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP478: Initiating an Inpatient Stroke Education Class in the Acute Hospital Setting to Reduce Hospital Readmission Rates
Authors: Thomas Joshua M , Compian Breanna , Sanders Alicia , Owunna Abigail
Published: January 2019

Background:
The Joint Commission (TJC) with other organizations have laid out core measures for stroke; STK-8 measures stroke education provided to patients. At many acute hospitals, patients are provided with a packet of written materials, but language barriers and low patient literacy are challenges to this approach.

Hypothesis:
We propose that personalized, supplemental education will improve patients’ stroke literacy and lower stroke readmission rates.

Methods:
At St. David’s Medical Center (Austin, TX), we developed a stroke education class that is provided to patients, in addition to standard stroke discharge packet and discussion. Each class consists of the following: a 5-item quiz to assess prior knowledge and learning, a 10-minute presentation (this can be accessed via in-room video for immobile patients), and a Q & A session to address remaining questions. The class is available in English and Spanish; video interpretation is available for additional languages. The efficacy of this course will be assessed by comparing readmission rates in the 12 months before and after its implementation.

Results:
A total of 28 patients and family members have attended the class since 3/29/18. Among those who have completed the course, 28 (100%) patients have increased their post-test scores, indicating that information is being retained. The analysis of readmission rates will give us data as to whether this education is beneficial in the long-term. Based on our promising initial results, we plan to increase the frequency of these classes to 3 days/week to reach more patients.

Conclusion:
With promising early results and positive patient feedback, this project has the potential to reduce stroke readmissions. Additional data collection will occur to assess the educational improvement and outcomes with statistical significance. Our initial results suggest that the addition of this class will increase education retention.
Abstract TP48: Mechanical Thrombectomy for Large Vessel Occlusion in Acute Ischemic Stroke Patients Presenting After 6 hours of Symptom Onset—A Meta-analysis of Randomized Controlled Clinical Trials
Authors: Ishfaq Muhammad F , Aytaç Emrah , Gurkas Erdem , Qureshi Adnan I
Published: January 2019

Background:
The efficacy and safety of endovascular treatment for proximal large vessel occlusion after 6 hours of symptom onset have recently been studied in randomized controlled trials. We performed this meta-analysis to identify the combined effect of endovascular treatment on various outcomes in this patient population.

Methods:
We performed this meta-analysis of all available randomized controlled clinical studies that involved the use of endovascular treatment in after 6 hours of symptom onset. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using random-effects models. The primary end point was a favorable outcome defined by a modified Rankin Scale (mRS) of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Other outcome variables included symptomatic intracerebral hemorrhage, excellent outcome (mRS 0-1), and mortality at 90 days post-randomization.

Results:
Three trials were identified that included 447 patients. The proportion of subjects who achieved a favorable outcome was significantly greater among those randomized to endovascular treatment compared with best medical treatment (445 subjects analyzed; OR 4.34; 95% CI, 2.65-7.14; P < .001). Excellent outcome was also significantly greater among those randomized to endovascular treatment (445 subjects analyzed; odds ratio, 3.29; 95% CI, 1.98-5.46, P < .001). Risk of symptomatic intracranial hemorrhage and mortality were similar between endovascular treatment and best medical treatment with p-value of 0.320 and 0.375, respectively. No risk of heterogeneity was observed in any of outcome variables.

Conclusion:
We found a prominent benefit (4 times higher odds) with endovascular treatment in appropriately selected patients with large vessel occlusion ischemic stroke presenting after 6 hours of symptom onset
Abstract TP489: Atrial Fibrillation Detection Following Implanted Cardiac Monitor Placement in Patients with Embolic Stroke of Undetermined Source
Authors: Milner Sherilyn A
Published: January 2019

Objective:
Determine atrial fibrillation detection rates in patients with ischemic stroke and TIA following implanted cardiac monitor placement.

Introduction:
Annually an estimated 795,000 Americans suffer a stroke. Embolic stroke of undetermined source (ESUS) is estimated to account for 25-30% of all ischemic strokes. While atrial fibrillation is associated with an increased risk of ischemic stroke, AF is often asymptomatic. Current guidelines recommend antiplatelet therapy for secondary stroke prevention in ESUS. Unfortunately the prevalence of atrial fibrillation in ESUS is unknown. Thus detection of asymptomatic AF in ESUS has potential therapeutic implications.

Methods:
To determine the frequency of asymptomatic AF, a retrospective chart review was conducted of patients admitted to a single center 627 bed quaternary referral hospital and certified comprehensive stroke center in Hennepin County, Minnesota. Between June of 2015 and June of 2018, 237 implanted cardiac monitors (ICM) were placed in patients with a primary diagnosis of stroke or TIA. Inclusion criteria was admission to the stroke center or evaluation in the TIA clinic, primary diagnosis of ischemic stroke or TIA, diagnosis of ESUS, and placement of ICM. Diagnosis of ESUS was confirmed by the stroke medical director. Patients were monitored remotely for a minimum of six and a maximum of eighteen months post ICM insertion. Remote monitoring was discontinued at time of AF detection confirmed by an electrophysiologist. Medication adjustments were directed by the stroke service.

Results:
Multivariable analysis will be reported to compare patients with positive and negative AF detection, age, sex, ethnicity/race, and CHA
2
DS
2
-VASC score. Hazard ratios will be calculated for AF detection at 6 and 12 months post ICM insertion.

Conclusion:
Since AF is often asymptomatic, cardiac monitoring plays an important role in evaluation of ESUS. Detection of AF often results in initiation of anticoagulation which is superior to antiplatelet agents for stroke prevention in AF. Identifying asymptomatic AF may reduce recurrent stroke rates in ESUS.
Abstract TP49: Trends of Patent Foramen Ovale (pfo) Closure From 2008 to 2014 at National Level: Us Experience
Authors: Khatri Rakesh , Afzal Mohammad Rauf , Vellipuram Anantha , Maud Alberto , Cruz-Flores Salvador , Rodriguez Gustavo
Published: January 2019

Introduction:
Evidence for patent foramen ovale (PFO) closure has been controversial, as was reflected in the guidelines published by AHA/ASA in 2014. Prior to 2014, three randomized controlled trials compared PFO closure and medical management. Evidence of PFO closure was lacking however PFO closure was being performed in both trial settings and non-trial settings.

Methods:
We analyzed the Nationwide Inpatient sample (NIS) from 2008 to 2014. Ischemic stroke (IS) patients with primary diagnosis using ICD 9 codes were selected along with secondary diagnosis of PFO/ ASD (ICD 9 code: 745.5). Further we selected the patients who underwent the PFO closure procedure using ICD 9 procedure codes: 35.51 and 35.52. We evaluated the rate of PFO closure, characteristics of patients receiving closure and evolution of trend during that time period at the national level.

Results:
Total number of patients admitted over 7 years in US with Ischemic stroke associated with PFO was 77964. Only a minority of patients [n=1487 (1.9%)] received PFO closure and about half were females (50.2%). Majority of treatments (70%) were performed in teaching hospital setting. Patients who underwent PFO closure were younger, mean age 55.3 years (± SD 16.6) years versus 61.4 years (± SD 16.7) (p< 0.001) in patent who did not receive closure. Medical comorbidities were significantly lower in group receiving treatment (Congestive heart failure 0.9% vs. 7.6%, hypertension 55% vs. 64.6%, atrial fibrillation 6.9% vs. 11.6%) but no difference was noted in deep venous thrombosis, pulmonary embolism and diabetes mellitus. We noted a significant downward trend of PFO closure at the national level and at teaching hospitals over 7 years (see graph 1)

Conclusion:
National database demonstrated that only a minority of patients received PFO closure in setting of ischemic stroke and overall a downward trend was noted over the years in setting of negative randomized trials.
Abstract TP491: When Your ER Doc Goes Down:The Power of a Nurse-Initiated Protocol
Authors: Fulmer Ahna
Published: January 2019

Background:
Emergency departments (ED) across the nation are implementing stroke protocols in order to rapidly identify and treat patients having an acute ischemic stroke (AIS). By making this protocol nurse-initiated, whereby nurses can implement the process independent of an ED physician, the mobilization of resources for AIS patients occurs faster and creates an environment in which nursing plays an integral role in the team approach to care, thereby, improving nurse buy-in, and ultimately, patient outcomes.

Purpose:
To empower nurses to independently initiate a stroke protocol.

Method:
A nurse-initiated stroke protocol was implemented utilizing evidence-based practice to mobilize pre-hospital and in-hospital personnel in order to rapidly diagnose AIS and promote early intervention.

Results:
A stroke policy was implemented at our community hospital 3 years ago, and the value of the nurse-initiated protocol was displayed when the only ED provider in the department began to have a massive AIS. The rapid recognition and intervention by the nursing staff resulted in a neurology consult in 25 minutes and IV tPa in 46 minutes of last known well while also managing the care of an entire ED.

Conclusion:
In conclusion, research supports the use of nurse-initiated protocols and when empowered with education, supported by staff, and utilized to full scope of practice, nurses are able to independently identify and rapidly mobilize care for AIS.
Abstract TP493: Impact of Extended Window Protocol for Acute Stroke Treatment (EPAST) Implementation on Stroke Treatment Rates and Quality Indicators in Emergency Room
Authors: Aagesen Jon , Omelchenko Nataliya , Adkins Jeffery
Published: January 2019

Background and Purpose:
Acute ischemic strokes remain one of the main causes of morbidity and mortality in the United States (US). With a stroke occurring every 40 seconds, the interest in advancing stroke care is critical to improving survival and reduces the loss of function (Taylor, Uchino, Hussain, & Carlson, 2014). Presently, 12% of acute ischemic strokes evaluated in US Emergency Departments (ED) receive stroke intervention (Lin et al., 2015). The purpose of the extended window protocol for acute stroke treatment (EPAST) study was to evaluate it’s impact on stroke patients’ treatment rates and quality indicators (door to the needle (DTN) and door to groin (DTG) times). Patient outcome was measured by the change in the modified Rankin Score (mRS). The investigation also assessed a new nursing process, which extended the assessment and screening window for acute stroke patients presenting within the emergency department (Omelchenko & Cerone, 2017).

Methods:
A chi-square test of independence, an Independent t-test and Mann-Whitney U test were used for data analysis (Sheskin, 2011).

Results:
The study examined the stroke alerts during January-February 2017 to establish a baseline (n=8) vs. total stroke alerts during January-February 2018 identified as the sample (n=9). Study showed number of alerts at
X
2
(1) = .118,
p
= 0.732. The DTN baseline was 72.50 minutes vs. sample time of 64.75 minutes.
t
(7.031) = .374,
p
= 0.720. DTG baseline was 90.50 minutes vs. sample time of 70.00 minutes,
t
(2) = .179,
p
= 0.874. The mRS baseline median was 4.50 vs. sample median of 2.67 (
p<
0.05).

Conclusion:
EPAST project showed overall improvements in the stroke process quality indicators such as DTN and DTG with the average improvement of 11% and 22% respectively. Study also showed positive trends in overall stroke treatment rates, as it included additional patients who would be excluded in the past. Study was limited by small sample size. Additional studies are recommended in the future.
Abstract TP495: Barriers Identified Deterring Collection of Transition of Care Data in Hospitals Participating in Michigan Paul Coverdell Acute Stroke Registry
Authors: O'Brien Suzanne L , Nickles Adrienne V , Ibrahim Ghada , Wall Samantha R , Quartermus Krystal , Wahl Robert , Scorcia-Wilson Teri , Reeves Mathew J , Demel Stacie L
Published: January 2019

Background:
Each year roughly 800,000 Americans experience a stroke. With shortened hospital length of stay, many patients are discharged home with expectations to self-manage follow-up appointments, comply with medications, and modify life style factors. Coordination of transition of care (TOC) post-discharge provides an organized approach to ease treatment and compliance. Michigan’s Ongoing Stroke Registry to Accelerate Improvement of Care (MOSAIC) collects voluntary TOC data from participating hospitals and encourages additional hospitals to participate.

Objective:
To identify barriers MOSAIC hospitals encounter deterring participation in TOC data collection, provide recommendations for barrier elimination, and improve facilitation of care for discharged patients.

Design:
Qualitative observational study with use of follow-up survey.

Participants:
35 focus group call attendees participating with MOSAIC.

Methods:
Structured focus group with pre-determined free-response questions were conducted via phone call with participating hospitals. Upon completion, hospitals participating in the call received a follow-up survey to provide additional information not covered in the focus group discussion. Use of thematic analysis to identify commonality among hospitals experiencing barriers was conducted from compiled focus group notes from two recorders and follow-up survey data.

Results:
Based on a thematic analysis of focus group notes and follow-up survey responses, staffing resources was the most prevalent theme hindering MOSAIC hospitals from participating in TOC collection. Time issues, other required data reporting, data visualization, and form usability were also highlighted as deterring factors. Further, participants indicated that while not currently participating in collection, TOC data could be useful in decision making processes and quality improvement within their respective programs.
Abstract TP5: Prior Intravenous Thrombolytics Administration is Associated With Increased Hospital Bills & Intracranial Hemorrhage Rates Without Improved Outcomes in Mechanical Thrombectomy Patients
Authors: Hassan Ameer E , Kotta Hari , Garza Leeroy , Preston Laurie , Tekle Wondwossen G , Sarraj Amrou , Qureshi Adnan I
Published: January 2019

Background:
The efficacy of intravenous thrombolytics (IV TPA) administration in conjunction with endovascular treatment (EVT) has recently come into question. If IV TPA does not offer significant patient outcome benefits nor significantly reduce rates of endovascular complications, its additional cost may present as an unnecessary financial burden.

Objective:
To investigate whether significant differences exist in hospital bills and patient outcomes between patients who undergo EVT alone and patients who undergo EVT with IV TPA.

Materials and Methods:
We retrospectively grouped patients in an EVT database into those who underwent EVT and those who underwent EVT+IV TPA. Hospital encounter charges (obtained via the hospital’s charge capture process), final patient bills (i.e. negotiated final bills as per insurance/Medicare rates), demographic information, existing comorbidities, admission and discharge NIHSS score, and functional independence data (mRS 0-2) were collected. Univariate and bivariate statistical analyses were performed.

Results:
Of 254 total patients, 96 (37.8%) underwent EVT+IV TPA. Median NIHSS score at admission was significantly higher in the EVT+IV TPA group than the EVT group (p = 0.006). After adjusting for NIHSS admission score, EVT+IVTPA patient bills and encounter charges were still found to be $3,861.64 (95% CI: $658.84 - $7,064.45, p = 0.02) and $103,946.37 (95% CI: $76,717.21 - $131,174.97, p = 0.001) greater than the EVT only group respectively. The EVT+IV TPA group had a higher complication rate of intracranial hemorrhage (ICH) (p = 0.005). EVT and EVT+IV TPA groups did not significantly differ in median discharge NIHSS score (p = 0.56), in functional independence rate at 90 days (p = 0.96), nor in average hospital stay length (p = 0.21).

Conclusion:
Patients undergoing EVT + IV TPA are associated with greater hospital encounter charges and final hospital bills as well as higher rates of ICH than patients who undergo EVT only.
Abstract TP500: Cerebrovascular Artery Size is Age- and Sex-Dependent
Authors: Guilliams Kristin P , Gupta Niket , Musonza Clive , Ford Andria L , Goyal Manu S
Published: January 2019

Introduction:
Arteriopathy is a leading cause of pediatric stroke. Cerebral arteriopathies may be diffuse, such as in radiation or moyamoya arteriopathies, limiting contralateral normal comparisons. Normative data for comparison and identification of diffuse arteriopathy is not currently available. Cerebral blood flow has been shown to vary based on age and sex; therefore, we aimed to determine potential age- and sex-related differences in cerebral artery size.

Method:
Healthy children and young adults aged 4 - 40 years were recruited to undergo 3D time-of-flight magnetic resonance angiography (MRA). Motion-degraded studies were excluded. The mean diameters of segments of the internal carotid artery (ICA), middle cerebral artery (MCA), anterior cerebral artery (ACA), basilar artery (BA) and ophthalmic artery (OA) were manually determined using a double-oblique technique. Mixed model regression of vessel diameters determined significance of age and sex.

Results:
MRAs of 22 children (ages 4-21 years; 12 male) and 13 adults (ages 22-38 years; 9 male) were analyzed. On mixed model regression, younger participants maintained larger diameters for ICA (p=0.03), MCA (p<0.001), ACA (p<0.001) and BA (all p=0.007) without difference between sexes. OA diameter did not differ with regards to age or sex.

Conclusion:
Normal cerebral artery size in vessels contributing to brain perfusion is largest in younger children and diminishes with age, likely reflecting higher cerebral blood flows observed in younger children. Age-specific normative data is needed to identify diffuse cerebral arteriopathy in children and young adults.
Abstract TP501: The Pediatric Stroke Alert System: Evaluation of Time to Diagnosis and Treatment of Acute Childhood Stroke
Authors: Riggs Rebecca , Sun Lisa R , Catenaccio Eva , Gonzalez Torriente Adriana , Felling Ryan J
Published: January 2019

Introduction:
With increasing interest in using thrombolytic and endovascular therapies in children, primary pediatric stroke centers are emerging to more quickly diagnose and treat childhood stroke. Successful centers must have an effective multidisciplinary stroke alert system aimed at early diagnosis and treatment of pediatric stroke.

Objective and Hypothesis:
Our objective is to evaluate the pediatric stroke alert system at the Johns Hopkins Children’s Center. We analyzed all 120 activations from October 2014 to July 2017 to assess the time to stroke evaluation, neuro-imaging, hyper-acute therapies, and diagnosis.

Methods:
The pediatric stroke alert system can be activated by any medical provider in any location at the Johns Hopkins Children’s Center including the transport team. Criteria for activation is acute onset of a focal neurological deficit within 12 hours of presentation. Once activated, a neurology resident evaluates the patient immediately and a neuroimaging is completed if indicated.

Results:
There were 120 pediatric stroke activations with 80 (67%) from the ED, 10 (8%) from outpatient locations (outside hospitals, EMS, clinics, transport teams), and 30 (25%) from the inpatient setting (PICU, OR, pediatric floors). For patients on inpatient units (floor, PICU, OR) the average time from symptom discovery to activation was 255 minutes (n=28, SD=387). For patients in the ED the average time from ED arrival to activation was 43 minutes (n=68, SD=82). A neurology resident was at the patient’s bedside within an average of 5.5 minutes of activation (n=103, SD=14). MRI imaging was obtained an average of 113 minutes (n=70, SD=246) after evaluation. Overall, 21 children (18%) were diagnosed with stroke, 16 (13%) migraines, 25 (21%) seizures, 5 (4%) with infections, 8 (7%) functional, and 45 (38%) were not given a neurologic diagnosis. Intravenous tPA was given to 1 patient and endovascular therapy was performed in 2 patients.

Conclusions:
The pediatric stroke alert system has transformed the initial management of acute stroke and other emergent neurologic presentations at the Johns Hopkins Children’s Center, streamlining their evaluation and offering the potential for time-limited reperfusion therapies.
Abstract TP502: Childhood Cerebral Arteriopathy in Glycogen Storage Disease Type 1
Authors: Hong Yuehui , Yuan Yuheng , Hou Bo , Shu Shi , Dai Yi , Feng Feng , Qiu Zhengqing , Peng Bin
Published: January 2019

Introduction:
Glycogen storage disease type 1 (GSD1) is a rare genetic metabolic disorder caused by defects of glucose-6-phosphatase complex, resulting in a wide array of manifestations such as hepatomegaly, hypoglycemia and hyperlipidemia. Previously, cerebrovascular complications had been described in 7 pediatric or young patients. However, the mechanism remains unknown. This study aims to describe the phenotypes of 6 cases and explore the possible mechanisms of cerebral arteriopathy in GSD1.

Methods:
All patients with GSD1 and cerebral arteriopathy were included. Cerebral arteriopathy was demonstrated by MRA/DSA and classified according to anatomic and temporal features. Possible mechanisms were explored using vessel wall imaging and targeted or whole-exome sequencing.

Results:
In this single center study, 6 unrelated patients with GSD1 and cerebral arteriopathy were identified (4 females). Mutational analysis confirmed the diagnosis of GSD1a and 1b in 3 patients, respectively. The median age at neurologic onset was 9 years (range, 5-11 years). Unilateral and bilateral cerebral arteriopathies were observed in 3 patients (figure), respectively, resulting in ischemic stroke in 1, TIA in 2 and non-ischemic symptoms in 3 patients. Arterial lesions typically involved the bifurcation of internal carotid artery, with or without lenticulostriate collaterals. Follow-up MRA performed at 12-24 months’ interval in 3 patients showed progression of arteriopathy (arrows). Vessel wall imaging performed in 5 patients displayed shrinkaged lumen of affected segments without plaque. Carotid ultrasound ruled out subclinical atherosclerosis. Genetic analysis in 4 patients revealed no pathologic variants known to be associated with cerebrovascular disorder such as moyamoya disease/syndrome.

Conclusions:
Pediatric GSD1 patients might be predisposed to progressive steno-occlusive cerebral arteriopathy, probably through non-atherosclerotic mechanisms.
Abstract TP503: Screening Algorithm for Hereditary Hemorrhagic Telangiectasia in Pediatric Brain AVM
Authors: Wusik Katherine , Hammill Adrienne , Patel Manish , Vadivelu Sudhakar , Taylor J. Michael
Published: January 2019

Background:
Hereditary Hemorrhagic Telangiectasia (HHT) is a rare cause of familial arteriovenous malformation (AVM) which may present symptomatically in the brain, spine, pulmonary, or hepatic circulation. Symptoms and signs of HHT - including epistaxis, GI bleeding, and cutaneous telangiectasia - may not be manifest at the time of AVM diagnosis. Natural history studies suggesting a more benign course for HHT-associated AVM compared to sporadic AVM may reflect a sampling bias if the true frequency of HHT is under-estimated. In this study, we report our experience with HHT screening in a population with pediatric brain AVM.

Methods:
Patients followed in the multidisciplinary Cincinnati Children’s Hospital Cerebrovascular Center are interviewed by a genetics counselor after identification of a brain AVM. A comprehensive medical and family history are collected and patients are offered screening for HHT using a 5 gene panel (Ambry Genetics: ACVRL1, ENG, SMAD4, RASA1, GDF2). Further testing with bubble echocardiogram and skin examination is offered to identify clinical criteria for HHT per Curacao criteria.

Results:
Brain AVM was identified in 12 patients followed in our center with age range 5 weeks to 17 years at AVM diagnosis. Recurrent epistaxis was present in 6 (50%) of our patients. Family history is negative for HHT in all cases although 75% of patients had at least 1 first degree relative with recurrent epistaxis. Additional diagnostics were completed in 10 of 12 patients, including genetic testing in 9 individuals. No pathogenic mutations were identified in this small cohort but 2 patients showed variants of unknown significance in ENG (p.R3C and p.E41K). Of the 10 patients who completed additional screening for HHT, 2 met criteria for definite HHT (ages 3 and 17) and 2 for possible HHT (ages 2 and 10).

Conclusions:
In our cohort of pediatric brain AVM patients, 33% met criteria for possible or definite HHT. The clinical symptoms and signs of HHT emerge over time. Using a standard diagnostic algorithm for reassessment of Curacao criteria may help facilitate correct and timely diagnosis. For cases confirmed with definite HHT, genetic counseling and gene testing should be considered.
Abstract TP504: Development of a Smart-phone App for Fast and Accurate Pediatric NIHSS Administration
Authors: Fooladi Talari Hadi , Bartolini Luca , Anwar Tayyba , Parihk Neil , Cleary Kevin , Pergami Paola
Published: January 2019

Background:
The NIH stroke scale (NIHSS) is a standardized scale for evaluation of severity in stroke patient, and is utilized in adults with acute stroke to select patients for urgent intervention. A modified NIHSS has been validated for use in children (PedNIHSS). As pediatric stroke is rare, the PedNIHSS is not used frequently, and physicians are less familiar with the administration. Hence, this scale is used inconsistently, scoring can be less accurate, and important information is lost. We developed a smart-phone app for facilitated administration and recording of PedNIHSS in pediatrics.

Methods:
The PedNIHSS-App was built using the cross-platform software-developed environment Xamarin. Throughout development] validation and testing was performed with neurology colleagues. Feedbacks were collected from six pediatric neurologists for optimization. A web-based testing version was available during development.

Results:
Administration of the NIHSS stroke scale involves scoring 11 items of neurologic function. Administration of the PedNIHSS in children requires specific age-appropriate modification for testing and scoring. In the newly-developed PedNIHSSApp each item appears on a single page with clear explanations for administration and immediate scoring. Cartoons have been developed for visual instruction. Anonymously-recorded scoring -with no concerns for violation of confidentiality and/or dissemination of protected medical information- can be saved with a time stamp or sent via password-protected email.

Conclusion:
The user friendly, easy-to-use PedNIHSS App will facilitate accurate acquisition of PedNIHSS in children with acute stroke, particularly in situations when time is critical and standardized tools can support decision-making. Additionally, the easy to use PedNIHSS App will support increased data acquisition and therefore facilitate future outcome studies in pediatric stroke.
Abstract TP505: Activity After Stroke in Children
Authors: Kenny Amanda , Dobkin Bruce H , Stence Nicholas , Bernard Timothy J
Published: January 2019

Introduction:
Childhood stroke is a devastating disease with lifelong morbidity that can last decades. Post-stroke exercise habits may be particularly important for long-term health and secondary stroke prevention in adulthood. We hypothesized that children with stroke have decreased activity as compared to age and gender matched healthy controls.

Methods:
We enrolled 15 children from our IRB approved institutional stroke database and 15 controls to participate in a two-week study of daily activity (mean age=13 years, 80% female). Participants were asked to wear bilateral wireless ankle accelerometers with Bluetooth transmission to a smartphone around each ankle 8 hours or more a day for 14 days. Demographic data, activity patterns (i.e., total walking time, time spent sedentary, average walking speed), and compliance were recorded. Stroke size was measured by neuroradiologists as a percentage of total brain volume. We then compared the percentage of time sedentary between cases and controls via two-tailed t-test, as well as performed a regression analysis to determine the impact of stroke size upon activity levels.

Results:
Children with stroke wore monitors an average of 10 of the 14 requested days for an average of 9.6 hours each day, as compared to controls who averaged 9 of the 14 requested days for an average of 10.6 hours each day. As expected, children with stroke show a slightly slower walking speed of 1.17 meters per second as compared to controls at 1.2 meters per second. While children with stroke walked a similar number of hours per day as the control group (1.42 for cases vs 1.48 for controls), both groups were sedentary a great percentage of time (85% vs 86% respectively, P=0.38). Patients with larger strokes did not record less activity than peers with smaller strokes (P=0.823).

Conclusion:
Activity levels in children after stroke are comparable to their age and gender-matched peers, although less than ideal in both groups. In addition, stroke size did not have an impact upon activity levels in children with stroke. These findings suggest activity studies are feasible in this population, and will need to be confirmed in larger prospective studies. Low overall levels of activity may still represent an opportunity for intervention in this population.
Abstract TP506: Decreasing the Time to Detection of Stroke After Cardiac Catheterization in Children
Authors: Harrar Dana B , Brown Loren , Bernson-Leung Miya , Vittner Patrick , Sen Sonali , Salussolia Catherine L , Kapur Kush , Chao Jessica H , Fialkow Alexandra , Kiran Maski , Rivkin Michael J
Published: January 2019

Introduction:
Children with congenital and acquired heart disease are at high risk for stroke. One-quarter of acute ischemic strokes (AIS) in children with cardiac disease occur in the peri-procedural period. Children with AIS can be treated successfully with hyperacute therapies. However, this requires timely identification of stroke, which has historically proved challenging in children. By developing and implementing a standardized screening assessment, we aim to decrease the time to detection of strokes occurring after cardiac catheterization in children.

Methods:
We retrospectively reviewed the medical records of children who had a stroke after cardiac catheterization at a tertiary children’s hospital between December 2006 and July 2016. We then developed a standardized screening stroke assessment. This was incorporated into the electronic medical record, and cardiology bedside nurses were trained in its use. The performance of the screen was analyzed retrospectively for children with a known stroke after cardiac catheterization.

Results:
Twenty children had a clinically-apparent stroke after cardiac catheterization prior to implementation of our screen. The time from the end of catheterization to the first documented assessment of neurologic function in any domain ranged from 22 minutes to 3.3 days (median 126 minutes). Given this variability, we developed a screening assessment that is brief, feasible, and within the scope of practice of cardiology bedside nurses. This was introduced to all nurses involved in the acute assessment of children after cardiac catheterization and is now performed on all children after catheterization. Retrospective application of the screen to the 20 children with a post-catheterization stroke would have resulted in detection of 18 (90%) of these strokes.

Conclusion:
Stroke after cardiac catheterization in children is rare; however, it is accompanied by a high rate of morbidity and mortality. The diagnosis of stroke after cardiac catheterization is often delayed. Development of screening methods to rapidly identify stroke in this population is feasible and has the potential to decrease the time to detection of stroke, thereby expanding access to hyperacute therapies.
Abstract TP507: Sex-Related Differences in Neonatal Stroke: International Maternal Newborn Stroke Registry
Authors: Lee So , Cavanaugh Beth Anne , Kirton Adam , Mackay Mark , Leffert Lisa , Fink Matthew , Hernandez-Chavez Marta , Majersik Jennifer J , Christudass Christhunesa S , Aaron Sanjith , Grefe Annette , Ostrander Betsy , Bushnell Cheryl D
Published: January 2019

Background:
There is evidence that male neonates have higher incidences of ischemic stroke and associated limitations in brain repair compared to female neonates. We used data from the International Maternal Newborn Stroke Registry (IMNSR) to further explore neonatal sex differences in demographics, birth characteristics, stroke onset, and maternal factors.

Methods:
Eleven international sites participated; 8 entered data for this analysis. Eligible participants with newborn (28 weeks gestation to 28 postnatal days) ischemic or hemorrhagic stroke or cerebral venous thrombosis were identified prospectively and retrospectively and enrolled. Preterm infants born before 28 weeks and neonates with germinal matrix intraventricular hemorrhage were excluded. We collected APGAR scores at 1 and 5 minutes, resuscitation status, demographics, stroke type, maternal and gestational age at birth, and mother’s health conditions at birth. Descriptive statistics were performed to identify differences in female versus male neonate cases related to demographics, pregnancy-related factors, and birth-related factors.

Results:
We analyzed 68 cases, 38 males and 30 females. Median maternal age for all cases was 31 y (IQR 29-34). Compared to females, males were more likely to have a lower APGAR 1 score and receive resuscitation, and more likely to have a stroke onset within the first week of life. This data set did not show significant gender-related differences in stroke type, or maternal health concerns during pregnancy (Table).

Conclusions:
We found that males with newborn strokes had more complications at birth and were more likely to have strokes present in the first week of life than females. Further research on the reasons for these sex differences is needed.
Abstract TP508: Neuropsychological Outcomes in Children With Arterial Ischemic Stroke
Authors: Taylor J. Michael , Vadivelu Sudhakar , Kinnett Douglas , Byars Anna
Published: January 2019

Objective:
Pediatric stroke is a rare disease with potential for lifelong impact on cognition, social function, and financial productivity. Neuropsychological testing is critically important for understanding the impact of acquired brain injury on the component elements of cognition. Unfortunately patients cannot always access comprehensive testing resources due to a variety of barriers including limited behavioral health provider availability, cost, and insurance coverage. Physicians must be familiar with common neurocognitive difficulties after pediatric stroke to aide timely resource referral. In our study we review the neuropsychological profile of pediatric arterial ischemic stroke (AIS) patients.

Methods:
This is a single center retrospective case series of AIS patients evaluated from 2015-June 2018 by our multidisciplinary cerebrovascular center. Patients were referred for neuropsychology evaluation routinely after identification of stroke. The test battery was determined at the discretion of the evaluating psychologist and administered per standard protocol. Aggregate results are presented with mean ± standard deviation. Medical records have been abstracted and correlated to lesion laterality, time elapsed since injury, and neurologic comorbidities including ADHD and epilepsy.

Results:
The CV center cares for 120 children with AIS. 38 children have undergone neuropsychological testing in the study interval (23 females, 15 males). Median age at evaluation is 12 years. The mean full scale IQ for this cohort is 81±18 scoring in the low average range compared to the healthy population. The cohort showed lowest performance in visual spatial index (83±15) and working memory (84±16). Verbal comprehension (89±18), fluid reasoning (87±13), and processing speed indices (85±16) showed minimally higher scores. Conclusion Children with stroke are at risk for cognitive deficits with visual spatial and working memory difficulties most prominent in our cohort. Appropriate therapeutic and educational resources should be directed to address cognitive deficits when identified. Clinician recognition of support needs in this population will facilitate timely referral for intervention.
Abstract TP509: Patterns of Injury in Children With Perinatal Arterial Ischemic Stroke and Infantile Spasms
Authors: Srivastava Ratika , Shaw Oriana , Armstrong Edward , Morneau-Jacob Francois-Dominique , Yager Jerome Y
Published: January 2019

Perinatal arterial ischemic stroke (AIS) occurs in 1 in 4000 live births and is the most common stroke in children. Consequences include seizures and a spectrum of cognitive and motor disability. Infantile spasms (IS) is an epileptic encephalopathy of infancy with an incidence of 2 in 10,000 live births. Approximately 5% of IS is caused by perinatal AIS. Patterns of ischemic injury that may predispose infants to IS and predict treatment response have not yet been identified. This retrospective case series of infants with AIS and IS provides detailed descriptions of ischemic distribution, seizure presentation, treatment and outcomes. Inclusion criteria were: term birth, ischemic stroke or encephalomalacia in an arterial distribution identified or presumed to have occurred in the perinatal period, a diagnosis of infantile spasms. Patients with a watershed pattern of injury were excluded. The modified pediatric ASPECTS was used to qualify and quantify the type and distribution of stroke. Areas of injury were identified on MRI and scored from T2/Flair or DWI sequences. Eleven patients with AIS and IS were identified. Of nine who fit inclusion criteria, all had MCA territory involvement with 6/9 having basal ganglia injury. Five had ischemia identified retrospectively after developing IS and four presented as neonates. The highest ASPECTS (bilateral deep MCA) was associated with the worst outcome in motor function and epilepsy control. However, the second-highest ASPECTS (unilateral MCA, bilateral ACA) had mild motor deficits and no seizure recurrence after IS resolution. The three lowest ASPECTS (<10) involved unilateral cortical MCA strokes sparing the deep structures, and also had the best motor outcome and seizure control. The co-occurrence of perinatal AIS and IS often results in significant neurologic disability. Although there was no defined pattern of regional homogeneity, there was a trend towards basal ganglia injury with progression of epilepsy after IS. This study highlights that size of ischemic injury may be less important than location as a predictor of motor outcome and seizure intractability. Future research will focus on identifying areas of injury that may confer increased risk of IS compared to stroke patients who remain seizure-free.
Abstract TP511: Disparities and Temporal Trends in the Use of Anticoagulation in Patients With Atrial Fibrillation: The FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study
Authors: Sur Nicole B , Wang Kefeng , Di Tuillo Marco R , Gutierrez Carolina M , Dong Chuanhui , Koch Sebastian , Gardener Hannah , Garcia Enid J , Zevallos Juan C , Burgin W. Scott , Rose David Z , Goldberger Jeffrey J , Romano Jose G , Sacco Ralph L , Rundek Tatjana
Published: January 2019

Background:
Ischemic stroke (IS) is a known effect of atrial fibrillation (AF) and is largely preventable with the use of systemic anticoagulation. Direct oral anticoagulants (DOACs) effectively prevent IS in patients with AF, but DOAC utilization patterns vary. The goal of this study is to identify race-ethnic and sex disparities for the use of DOACs, aspirin, and warfarin at hospital discharge in IS patients with AF, and to identify temporal trends in the utilization of these medications in a large hospital stroke registry in Florida and Puerto Rico.

Methods:
The FLorida PuErto Rico Atrial Fibrillation (FLiPER-AF) Stroke Study included 28,036 IS cases enrolled in the Florida-Puerto Rico Collaboration to Reduce Stroke Registry from 2010 to 2017. Multivariable logistic regression models were performed to evaluate the effect of race-ethnicity and sex on utilization of DOACs, aspirin and warfarin for stroke prevention in AF after adjustment for systems of care, individual and clinical factors, including CHA2DS2-VASc scores.

Results:
Among 28,036 IS cases, 74% were women and 9.9% Black, 12.5% FL Hispanics, 3.3% PR Hispanic and 74.3% whites. Overall, DOAC use increased from 0% in 2010 to 44.3% in 2017, while warfarin use decreased from 55.0% to 13.5%, in 2010 and 2017, respectively. Aspirin use remained stable overall, 42.3% in 2010 and 43.8% in 2017. After adjustment, Blacks had lower odds of being discharged on DOACs (OR=0.85, 95% CI 0.77-0.94) and higher odds of being discharged on warfarin (OR=1.13, 95% CI 1.02-1.25) compared to Whites. Men had higher rates of aspirin (42.1% vs 38.8%), warfarin (33.6% vs. 28.9%) and DOAC (21.3% vs, 19.3%) prescription compared to women. After adjustment, women had lower odds of being discharged on aspirin (OR=0.91, 95% CI 0.86-0.96) or warfarin (OR=0.90, 95% CI 0.85-0.96); however, there was no difference in use of DOACs.

Conclusions:
Our study confirmed the increasing use of DOACs and down-trending use of warfarin in IS patients with AF. However, Blacks were discharged on DOACs less frequently than Whites and women were discharged on anticoagulation less frequently than men. Further studies to understand underlying drivers of these disparities are needed to develop better practice strategies for stroke prevention for AF.
Abstract TP513: Plasma Galectin-3 Predicts Functional Outcome After Acute Ischemic Stroke
Authors: Hansen Christina A , Wolcott Zoe , Woodburn Rebecca , Kimberly W. T
Published: January 2019

Introduction:
Galectin-3 (Gal-3) is a member of the beta-galactoside-binding protein family that has been implicated in cardiovascular disease and stroke. We sought to determine if baseline Gal-3 predicts functional outcome after acute ischemic stroke, and to compare its performance relative to several other prognostic biomarkers.

Methods:
We measured plasma Gal-3, soluble ST2 (sST2), and fatty acid binding protein 4 (FABP4) in 383 patients who presented with acute ischemic stroke and were enrolled in a two-center biomarker study. Additional analyses that include copeptin are currently underway. Functional outcome was assessed at 3 months with the modified Rankin Scale (mRS), with good outcome defined as mRS 0-2, and poor outcome defined as mRS 3-6. The relationships between each marker and outcome were evaluated using univariate and multivariate logistic regression.

Results:
Median admission Gal-3 level was 7.4 ng/mL [IQR 5.2-11.7], median sST2 was 41.3 ng/mL [IQR 30.1-57.3] and median FABP4 was 37.8 ng/mL [21.2-57.1] in 383 patients (mean age 69+/- 15 years; 41.5% women). In univariate analysis, each biomarker predicted poor outcome (Gal-3: OR 1.8, 95% CI 1.4 - 2.4, p<0.001, AUC=0.673; sST2: OR 1.6, 95% CI 1.2 - 2.0, p<0.001, AUC=0.612; FABP4: OR 1.9, 95% CI 1.4 - 2.6, p<0.001, AUC=0.592). After adjustment for age, sex, and NIHSS, Gal-3 remained an independent predictor of poor outcome (OR 1.5, 95% CI 1.1 - 2.0, p=0.019), but the other markers did not. However, both Gal-3 and sST2 were independent predictors of death at 3 months (Gal-3: OR 1.9, 95% CI 1.2 - 3.3, p=0.009, AUC=0.724; sST2: OR 1.7, 95% CI 1.1 - 2.6, p=0.027, AUC=0.689).

Conclusion:
Among three previously validated biomarkers, plasma Gal-3 level predicted 3-month functional outcome, and Gal-3 and sST2 predicted mortality. Replication in a second cohort is planned.
Abstract TP514: The Effect of Statin Adherence on Cardiovascular Outcomes After Ischemic Stroke in Statin Benefit Group: A Nested Case-Control Study
Authors: Park Jong-Moo , Kim Jun Yup , Kim Beom Joon , Kang Jihoon , Cho Yong-Jin , Park Kwang-Yeol , Lee Kyung Bok , Oh Mi-Sun , Chae Jaeeun , Lee Ji Sung , Kim Seong-Eun , Lee Heeyoung , Lee Juneyoung , Bae Hee-Joon
Published: January 2019

Backgrounds:
Irrespective of the indication for statin, statin adherence after ischemic stroke was associated with better clinical outcome. We studied the association between statin adherence and recurrent cardiovascular (CV) events among the patients with acute ischemic stroke and statin benefit.

Methods:
Using Comprehensive Registry Collaboration for Stroke in Korea (CRCS-K), patients with acute ischemic stroke were identified. Statin benefit was defined using the secondary prevention guidelines of American Stroke Association in 2014. The data for statin prescription after discharge were obtained from National Health Insurance Services (NHIS) claim data by matching with CRCS-K. Statin adherence was measured by the medication possession ratio (MPR), which was dichotomized, setting a threshold of MPR (<80%) to identify patients who were nonadherent. A nested case-control design was used to evaluate the occurrence of recurrent stroke, myocardial infarction, and all-cause mortality for 1 year after discharge. Each case was matched to 4 controls by age, sex, initial stroke severity and registry entry time. Adjusted conditional logistic regression models were used to estimate the odds ratio (OR) of CV events.

Results:
Among 11,768 patients in NHIS-CRCS-K matching database, 5,504 patients were the statin benefit group and prescribed with statin on discharge. Overall MPR for 1 year after discharge was 73.1%. Overall CV events for 1 year were 569, which was more prevalent in low adherence group. (MPR <80%, 18.0% vs. ≥80%, 6.5%, p<0.0001) In nested case-control data set, lower adherence to statin was associated with a higher risk of CV events compared with higher adherence (adjusted OR 1.496 [1.174-1.904]) after adjusting hypertension, diabetes mellitus, atrial fibrillation, history of stroke, history of antiplatelet drug use and discharge modified Rankin Scale score. Statin discontinuation was associated with higher risk compared with adequate statin prescription. (adjusted OR 2.075[1.622-2.655])

Conclusion:
Adequate statin adherence in the patients with acute ischemic stroke and statin benefit was significantly associated with recurrent CV events.