bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WMP17: Associations Between Post-Stroke Vascular Risk Factor Levels With Post-Stroke Cognitive Decline
Authors: Levine Deborah A , Gross Alden , Briceno Emily M , Han Dehua , Whitney Rachael , Ploutz-Snyder Robert , Chen Bingxin , Aparicio Hugo J , Beiser Alexa , Burke James F , Elkind Mitchell S , Giordani Bruno , Gottesman Rebecca F , Howard Virginia J , Koton Silvia , Lazar Ronald M , Manly Jennifer , Pendlebury Sarah T , Seshadri Sudha , Sharma Anupriya , Springer Mellanie , Sussman Jeremy B , Galecki Andrzej
Published: February 2022

Introduction:
Associations between post-stroke vascular risk factors levels with post-stroke cognitive decline are uncertain. We determined associations between systolic blood pressure (BP), glucose, and low-density lipoprotein (LDL) cholesterol levels with post-stroke cognitive decline.

Hypothesis:
Higher post-stroke systolic BP, glucose, and LDL cholesterol levels are associated with faster post-stroke cognitive decline.

Methods:
This cohort study pooled data from 832 participants 18 and older with incident stroke and free of dementia before stroke (50% women and 32% Black) from 4 cohort studies from 1971-2019: Atherosclerosis Risk in Communities Study, Cardiovascular Health Study, Framingham Offspring Study, and REasons for Geographic and Racial Differences in Stroke Study. Linear mixed-effects models were used to estimate longitudinal changes in cognition after incident stroke. The primary outcome was change in global cognition. Global cognition was harmonized across studies and standardized as T-scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition. Median (IQR) follow-up was 5.5 (3.3-8.3) years.

Results:
In separate models, higher post-stroke glucose and LDL levels, but not systolic BP, were associated with faster declines in global cognition (Models M1a, M1b, and M1c, Table 1). In a model with all three vascular risk factors, higher post-stroke mean glucose and LDL levels were associated with faster global cognition decline, though not to traditional levels of statistical significance; however, post-stroke mean systolic BP was not associated with global cognition decline (Model M2, Table 1). Older age was associated with faster cognitive decline in all models.

Conclusions:
Our results suggest that higher post-stroke glucose and LDL levels are associated with faster post-stroke cognitive decline. We found no evidence that post-stroke BP levels are associated with post-stroke cognitive decline.
Abstract WMP19: Cumulative Vascular Risk Factors Exposure During Young Adulthood And Brain Structure In Midlife
Authors: Lineback Christina , Mahinrad Simin , Chen Yufen , parrish todd , Lloyd-jones Don , Sorond Farzaneh A
Published: February 2022

Objective:
Vascular risk factors (VRF) are known contributors to brain health in old age, with minority populations disproportionately impacted. The role of duration and severity of exposure to VRF remains unclear. We examined the association between cumulative exposures to VRF (cVRF) from young adulthood to midlife and midlife brain health, while addressing racial differences.

Methods:
142 participants (39% black, 42% women) from the Coronary Artery Risk Development in Young Adults study with longitudinal VRF data over 30 years and a brain MRI at Y30 were included. Cumulative blood pressure (cBP), cholesterol, BMI, smoking, and glucose was calculated as the mean of two measures across two consecutive visits, multiplied by the number of years between visits from Y0 to Y30. Multivariate linear regression models including all VRF, demographics, and medications were used to assess the independent association of cVRF with brain MRI outcomes across races.

Results:
Higher cSBP was associated with lower total brain, gray matter, and hippocampal volumes in blacks, but not in whites (interaction p<0.05, Table1), independent of other cVRF. Similarly, higher cDBP was associated with lower total brain and hippocampal volumes only in blacks, but not in whites (interaction p<0.05, Table1). However, when examining these relationships across comparable cBP exposure levels, race differences were no longer significant. There was no interaction between race and other cVRF in relation to white matter hyperintensities, gray matter thickness or cerebral perfusion (interaction p>0.05).

Conclusions:
Exposure to higher BP across young adulthood is associated with midlife brain structure, possibly irrespective of race. Given higher level of cBP exposure in minorities, our observations should encourage clinicians to be aggressive in addressing hypertension in young adults, especially in young minority populations as a potential target to narrow disparities in brain health.
Abstract WMP27: Practice Makes Perfect. Does Obtaining Nihss Certification Assure Nurse Competence And Confidence?
Authors: Wolber Nicole E , Izzo Rachel E , Paletz Laurie B , Figueroa Sonia
Published: February 2022

Background:
Competent, confident nurses are key to maintaining patient safety, promoting trust, and achieving good patient outcomes. As a Certified comprehensive stroke center, documentation of the National Institute of Health Stroke Scale (NIHSS) is required within 12 hours of admission. Nurses are required to complete an online course to be certified in the NIHSS. During rounds with neurology staff nurses, questions were raised about proficiently performing the NIHSS. The team wondered if an online certification of NIHSS assures competence and confidence performing the scale at bedside?

Objective:
To evaluate neurology staff nurse competence and confidence performing the NIHSS.

Methods:
From April 2021 to June 2021, neurology staff nurses on all shifts were randomly sampled to for an NIHSS spot check evaluation. Nurses rated their confidence, pre and post NIHSS spot check, utilizing a Likert scale from 1-5, 1=not confident, 2= somewhat confident, 3=neutral, 4=confident, 5=Very confident. The NIHSS was evaluated for competency utilizing two criteria; one point for performing the scale item correctly, and one point for scoring the item correctly, with a goal of 100% to achieve competency.

Results:
NIHSS spot checks significantly increased neurology staff nurses’ confidence and highlighted key areas of improvement for all participants. A total of 17 neurology staff nurses were randomly sampled from day and night shift. Average baseline confidence score was 3.8. Of those nurses, 64% increased their confidence level 1-point and 9% increased their confidence more than 1-point post evaluation. Ultimately, 100% of nurses were found to achieve competency on the NIHSS spot check.

Conclusion:
Neurology staff nurses were eager to be evaluated, expressing genuine interest in improving their practice. Spot checking nurses illuminated areas of improvement and provided much needed reassurance to nurses that were competent but not necessarily confident. A competent and confident nurse promotes safety and trust in their patients and assures good patient outcomes. This project demonstrated that NIHSS certification reflected competency and illustrated the value of periodically evaluating nurses 1:1 to provide re-education and promote confidence in practice.
Abstract WMP33: Longitudinal Use Of The American Stroke Association Time Tracker Tool To Reduce Door To Needle And Door To Device Times In Stroke
Authors: Sarafin Jo-Ann M , Harmon Melissa , Yaghi Shadi , Burton Tina , Cutting Shawna M , Furie Karen L
Published: February 2022

Introduction:
The faster IV Alteplase and mechanical thrombectomy is initiated in acute ischemic stroke, the better the outcome. Delays can significantly impact times to treatment. A mechanism to communicate time targets to code stroke teams can play an important role in providing knowledge about time sensitive metrics. The utilization of the ASA Stroke Time Tracker tool was created to improve communication in a timely manner to stroke teams providing acute treatment. The emphasis is on the education of time targets to improve door to treatment times.

Hypothesis:
To explore whether the use of the American Stroke Association Time Tracker tool as a communication instrument is associated with improved DTN and DTD times in both direct and transfer patients.

Methods:
In March 2020 the application of the ASA time tracker tool was introduced. A retrospective review revealed that DTN times improved from 58.7% to 71.6 % for those receiving t-PA within 45 minutes or less during the period the tool was in use. To explore whether timely feedback using the Time Tracker tool was associated with improved DTD times, mechanical thrombectomy data including DTD was collected and communicated to stroke care teams in April 2021. Compilation of time sensitive metrics in the evaluation of DTN times continued through Q2 2021. A retrospective analysis was conducted.

Results:
For those who received IV Alteplase, the percentage of patients treated within 30 minutes continued to improve, 21.1% (Q3 2020) vs. 35.7% (Q2 2021). The percentage of patients treated within 45 minutes also improved from 71.8% (Q3 2020) to 80.0% (Q2 2021). In patients who received endovascular therapy during Quarter 3 2020, 56.1% met the advanced therapy AHA Elite Plus criteria of DTD within 60 minutes (transfer patients) OR within 90 minutes (direct admit). This improved to 73.1% patients in Quarter 2 2021, during the use of the tool.

Conclusions:
There is an association between use of the ASA Time Tracker tool and improved DTN and DTD times. Further study should include continued use of the tool to confirm an association between direct communication with Code Stroke teams and improved treatment times.
Abstract WMP37: Differential Montage Effect On Cortical Excitability In Ischemic Stroke Patients By Single Session Of High Amperage Transcranial Direct Current Stimulation
Authors: Chhatbar Pratik Y , Grattan Emily , Hutchison Scott , Ramakrishnan Viswanathan , George Mark S , Kautz Steven A , Feng Wuwei
Published: February 2022

Background and Objective:
We aim to assess the cortical excitability under three montages with single session of transcranial direct current stimulation (tDCS) at 4 mA on ischemic stroke patients.

Methods:
Adult subjects with first-ever unilateral ischemic stroke ≥6 months and inducible motor evoked potentials (MEP) underwent 3 sessions (washed out ≥2 days apart) of 30 minutes 4 mA tDCS in anodal, cathodal or bihemispheric montage (in pseudorandom order) combined with t upper extremity repetitive task training administered by an Occupational Therapist. We collected MEP responses to transcranial magnetic stimulation (TMS) single pulse, short intracortical inhibition (SICI, 3 ms) and intracortical facilitation (ICF, 15 ms) on bilateral abductor pollicis brevis (APB) muscles at baseline and four post-stimulation timepoints 12 minutes apart. We also monitored safety by recording adverse events, surveying subjects with a questionnaire on tolerability issues and collecting biometric measures (body resistance, skin temperature under the tDCS electrode).

Results:
Eighteen subjects completed 54 tDCS sessions in total. We observed montage (
P
<0.0001) and time (
P
<0.01) effects only on the lesioned hemisphere, with bihemispheric tDCS showing relatively higher peak-to-peak MEP. Lack of montage effect in baseline (
P
>0.949) suggested sufficient washout interval across the visits. No subjects experienced any adverse events. Biometric measures and tolerability were comparable across the three montages. The most common tolerability issue was transient redness under the tDCS electrodes (70% at anode, 48% at cathode).

Conclusions:
The bihemispheric montage increased ipsilateral cortical excitability the most in a single session of 4 mA tDCS in chronic ischemic stroke patients. Additionally, a current level of 4 mA is safe and tolerable over multiple sessions.
Abstract WMP44: Complications Of Implanted Vagal Nerve Stimulation: A Systematic Review And Meta-analysis
Authors: Kalagara Roshini , Chennareddy Susmita , Mocco J D , Kellner Christopher P , Panov Fedor
Published: February 2022

Introduction:
Vagus nerve stimulation (VNS) is a surgical technique that has been used to modulate disease processes by activating the parasympathetic system and has been used to treat conditions such as epilepsy and depression. More recently, VNS has been a promising tool in ischemic stroke rehabilitation. However, there has been no literature summarizing the adverse effects of this procedure, information that is critical for both patients and providers when obtaining informed consent for this novel treatment. This systematic review and meta-analysis aims to report the adverse effects of VNS.

Methods:
A systematic review was performed in accordance with PRISMA guidelines in order to identify common complications after VNS therapy. The search was executed in three databases: Cochrane Central Register of Controlled Trials, Embase, and Ovid MEDLINE. All prospective, randomized controlled trials using implanted VNS therapy in adult patients were eligible for inclusion. Case studies and studies lacking complete complication reports were excluded. Extracted data included technology name, location of implantation, follow-up duration, purpose of VNS, and adverse event rates.

Results:
After title-and-abstract screening of 4933 studies identified by the created search strategy, 21 studies were selected for final inclusion. Included papers studied VNS as a potential therapy for epilepsy (9), depression (8), anxiety (1), ischemic stroke (1), chronic heart failure (1), and fibromyalgia (1). In total, 1474 patients received VNS implantation in the 21 studies. The 5 most common post-implant adverse events were voice alteration/hoarseness (n=671, 45.5%), paresthesia (n = 233, 15.8%), cough (n = 221, 15.0%), dyspnea (n = 211, 14.3%), and pain (n = 170, 11.5%).

Conclusions:
Complications from VNS are relatively mild and transient, with reduction in severity and number of adverse events with increasing follow-up time. The most common complications included voice changes or hoarseness, increased cough, and pain with swallowing after surgery. In summary, VNS presents a powerful tool for the treatment of many difficult-to-treat conditions. In the future, the use of VNS in recovery after intracerebral hemorrhage should be explored.
Abstract WMP58: Association Of The Lace+ Score With Unplanned 30-day Hospital Readmissions After Stroke
Authors: Grigoriciuc Eliza , Henninger Nils , Silver Brian , Kobayashi Kimiyoshi , Moonis Majaz , Osgood Marcey , Jun-oconnell Adalia H
Published: February 2022

The LACE+ score is used to predict unplanned 30-day hospital readmissions, but its association with 30-day readmission after stroke is unknown. We retrospectively analyzed 1,656 consecutive patients presenting with strokes, included in an institutional stroke registry between January 2018 and August 2020. The primary outcome of interest was unplanned 30-day readmission. The 30-day readmission risk was categorized by LACE+ scores: high risk (>81), medium high (59-80) and medium risk (29-58). Kaplan-Meier curve, Log rank test, and multivariable cox regression analysis (with backward elimination) were used to determine whether the LACE+ score was associated with 30-day readmission. The overall incidence of 30-day unplanned readmission was 11.7% (194/1,656). The median LACE+ score was higher in the 30-day readmission group compared to subjects that had no unplanned 30-day readmission (74 (IQ 67-79) vs. 70 (IQ 62-75); p<0.001). On univariate analysis, readmitted patients were older, had a longer index admission length of stay, higher index admission cost, were more likely to be discharged to inpatient rehab, and with higher presence of hypertension, diabetes, history of prior stroke/TIA, and cardiovascular risk factors (p<0.05, each) as compared to non-readmitted group. On Kaplan-Meier analysis, the cumulative 30-day readmission free survival stratified by LACE+ risk category was lowest in the high-risk group and greatest in the medium risk group (Log-rank p<0.001). On multivariable Cox-regression, LACE+ score was independently associated with the unplanned 30-day readmission risk (HR 1.033; 95% CI 1.017-1.050, p<0.001) after adjustment for other variables. This is the first study looking at the association between LACE+ scores and unplanned readmissions in stroke, noting higher LACE+ scores associated with a greater unplanned 30-day readmission after stroke. Future studies on 30-day readmission risks in stroke are needed for quality improvement.
Abstract WMP59: Trends And Predictors Of Delay In Hospital Presentation After Symptom Onset Among Ischemic Stroke Patients: A Single-center Study
Authors: Okumu Rita , Baker Anna , Wira Charles R , Schindler Joseph L , Sansing Lauren H , Jasne Adam , Amin Hardik , Narula Reshma , Forman Rachel , Sharma Richa
Published: February 2022

Background:
Delivery of acute ischemic stroke therapies is contingent on the duration from last known normal (LKN) to emergency department arrival time (EDAT).

Methods:
We studied patients presenting to Yale-New Haven Hospital from 2010-2020 who met these criteria 1) ischemic stroke, 2) age ≥ 18, 3) not transferred from another hospital, and 4) stroke symptom onset prior to hospital presentation. The outcome was LKN to EDAT dichotomized at 4.5 hours. Temporal trends were assessed by linear regression. Covariates analyzed for association with later arrival were: age, gender, race, ethnicity, median household income < $50,000 by ZIP, arrival means, and NIHSS. We built a multivariable logistic regression model by stepwise selection with variables significant at p-value < 0.05).

Results:
We included 5,242 ischemic stroke patients; 1,964 (37.5%) presented early (<4.5 hrs). Patients presenting early decreased from 47.2% to 32.3% over time (p<0.01,
Figure 1
) and downward slope was steeper among non-White patients. Compared to early presenters, late presenters were more likely younger (median 72 vs 74 years; p<0.001), of non-White race (35.3% vs 26.8%, p<0.001), of Hispanic ethnicity (8.2% vs 6.2%, p=0.010), have a median household income < $50,000 (27.0% vs 21.2%, p=<0.001), arrive by means other than emergency medical services (EMS) (66.4% vs 85.8%, p<0.001), and have an NIHSS < 4 (57.5% vs 41.6%, p<0.001). In a multivariable model, non-White race (OR 1.4, 95% C.I. 1.2-1.7), arrival by means other than EMS (OR 2.4, 95% C.I. 1.9-3.0), and NIHSS < 4 (OR 1.6, 95% C.I. 1.3-1.9) were significant, independent predictors of presenting later.

Conclusion:
Frequency of ischemic stroke patients presenting beyond 4.5 hrs increased from 2010 to 2020. Non-White race, arriving by means other than EMS, and minor stroke symptoms were linked with delay in presentation. Further study is necessary to identify and target barriers to timely hospital presentation among ischemic stroke patients.
Abstract WMP66: Multiparametric Neuroimaging And Its Association With Non-Contrast Computed Tomography In Late Window Large Vessel Occlusion Acute Stroke
Authors: Rodrigo-Gisbert Marc , Requena Manuel , De Dios Lascuevas Marta , Garcia-Tornel Alvaro , Olive-gadea Marta , Boned Sandra , Muchada Marian , Deck Matias , Rodriguez-Villatoro Noelia , Rodriguez-Luna David , Juega Jesus M , Pagola Jorge , tomasello alejandro , Piñana Carlos , Hernandez David , Coscojuela Pilar , Ribo Marc , Molina Carlos A , Rubiera Marta
Published: February 2022

Background:
Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 to 24 hours is established as a standard of care among patients selected by multiparametric neuroimaging. Therefore, we aimed to explore neuroimaging parameters in late window AIS large vessel occlusion (LVO) patients and the association between findings in non-contrast computed tomography (NCCT) and multiparametric CT.

Methods:
We included consecutive AIS patients within 6-24 hours from symptoms onset with CTA-LVO. We studied potential associations between computed tomography mismatch defined by DAWN and/or DEFUSE-3 neuroimaging criteria (CTP-MM), infarct volume on CTP, and ASPECTS on NCCT. We also analyzed the association between neuroimaging parameters and outcome determined by 90-day mRS.

Results:
We included 206 patients, of which 176 (85.4%) presented CTP-MM and 184 (89.3%) presented with an ASPECTS ≥ 6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥ 6, as compared with 40.9% in those with low ASPECTS
[Figure 1A]
. The ASPECTS correlated with infarct core, determined by Cerebral Blood Flow <30% volume (rP=-0.575, P<0.001). In EVT-treated patients (185, 89.8%), after adjusting for identifiable confounders, the presence of CTP-MM was a predictor of 90-day functional independence (OR 3.38; 95%CI 1.01-11.29; P=0.048). We did not find an association between CTP-MM and 90-day functional disability (ordinal mRS shift, aOR 1.39; 95% CI 0.58-3.34; P=0.459)
[Figure 1B]
.

Conclusions:
A great majority of patients who presented a LVO in late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥ 6). Our data suggest that NCCT with CT angiography is a reasonable approach for acute ischemic stroke treatment selection also in the late window.
Abstract WMP71: Sequential Detection Rates Of Intramural Hematoma For Diagnosing Spontaneous Intracranial Artery Dissection
Authors: Hosoki Satoshi , Fukuda-doi Mayumi , Miwa Kaori , Yoshimura Sohei , Chiba Tetsuya , Ikenouchi Hajime , Morita Yoshiaki , Toyoda Kazunori , Ihara Masafumi , Koga Masatoshi
Published: February 2022

Introduction:
Spontaneous intracranial artery dissection (IAD) can be diagnosed with the detection of intramural hematoma (IMH). We previously reported that high-resolution 3-dimensional T1-weighted magnetic resonance imaging (HR-3D-T1WI) is useful to detect IMH. Limited evidence is available regarding sequential detection rates of IMH and appropriate timing of the detection.

Methods:
We retrieved data on consecutive patients from our prospective cohort databases from March 2011 to August 2018 who had definite, probable, or possible IAD based on the multidisciplinary expert consensus criteria. We detected IMH on initial and follow-up HR-3D-T1WI. We explored the association between detection of IMH and days from symptom onset to initial or follow-up HR-3D-T1WI.

Results:
A total of 104 patients (mean age 51 ± 13; 30 female; 68 patients, definite IAD; 31 patients; probable IAD, 5 patients; possible IAD) with at least initial HR-3D-T1WI data were included in the analysis. Clinical diagnoses included ischemic stroke (46%), subarachnoid hemorrhage (6%), transient ischemic attack (2%), and head or neck pain alone (46%). Age, Sex, vascular risk factors and modified Rankin Scale at 3 months were comparable between patients with IMH and without. Among them, follow-up HR-3D-T1WI was performed in 54 patients (52%). IMH was observed in 61 patients, 59% of all and 90% of definite IAD. The median days from symptom onset to initial or follow-up HR-3D-T1WI were 11 (interquartile range[IQR] 8–15) and 29 (IQR 19–57) days, respectively. The median days from symptom onset to first IMH detection were 12 (IQR range 8–17). The detection rate of IMH on initial HR-3D-T1WI was 55% overall, reaching 20% on day 3, 40% on day 7, and 50% on day 8–12 (
Figure
). Of the 23 patients who did not have an IMH on the initial HR-3D-T1WI, 4 (17%) had an IMH detected on the follow-up imaging.

Conclusion:
The detection rate of IMH on HR-3D-T1WI was approximately 60%, which reached the maximum in 1-2 weeks.
Abstract WMP81: Association Between Systemic Amyloidosis And Intracranial Hemorrhage
Authors: Chen Dora , Zhang Cenai , Jalil Syed M , Parikh Neal S , Merkler Alexander E , Fink Matthew E , Gupta Ajay , Sheth Kevin N , Falcone Guido J , Navi Babak , Kamel Hooman , Murthy Santosh B
Published: February 2022

Introduction:
Isolated amyloid deposition in the brain is associated with intracranial hemorrhage. Whether systemic amyloidosis also increases the risk of intracranial hemorrhage is unclear.

Methods:
We evaluated the association between systemic amyloidosis and intracranial hemorrhage using claims data from a 5% national sample of Medicare beneficiaries from 2008-2015. The primary outcome was non-traumatic intracranial hemorrhage, defined as a composite of intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hemorrhage. Secondary outcome were each hemorrhage type assessed separately. The exposure and outcomes were identified using previously validated ICD-9-CM diagnosis codes. We used Cox regression analysis adjusting for demographics and vascular risk factors to evaluate the association between systemic amyloidosis and intracranial hemorrhage. We also examined the risk of hip fracture (negative control). In sensitivity analyses, we excluded patients with cardiac amyloidosis, a subset most likely to be on antithrombotic therapy.

Results:
Among 1.8 million Medicare beneficiaries, 924 were diagnosed with systemic amyloidosis. During a median follow-up of 5.3 years (IQR, 2.8- 6.7), the cumulative incidence of intracranial hemorrhage was 19 per 1,000 patients per year among patients with amyloidosis, and 2 per 1,000 patients per year in those without amyloidosis. In adjusted Cox models, systemic amyloidosis was associated with an increased risk of intracranial hemorrhage (HR, 4.3; 95% CI, 2.9-6.3). The association persisted in a sensitivity analysis after excluding beneficiaries with cardiac amyloidosis (HR, 8.0; 95% CI, 5.0-12.7). In secondary analyses, systemic amyloidosis was associated with intracerebral hemorrhage (HR, 5.6; 95% CI, 3.6-8.7), subarachnoid hemorrhage (HR, 14.7; 95% 9.0-24.0), and subdural hemorrhage (HR, 3.6; 95% 2.0-6.2). There was no association between systemic amyloidosis and hip fracture (HR, 0.9; 95% CI, 0.6-1.4).

Conclusions:
In a large, heterogeneous national cohort of elderly patients, a diagnosis of systemic amyloidosis was associated with a 4-fold increased risk of intracranial hemorrhage, including intracerebral, subarachnoid, and subdural hemorrhages.
Abstract WMP82: Diffusion Tensor Imaging Is Independently Associated With Mobility After Intracerebral Hemorrhage
Authors: Demel Stacie L , Comeau Mary , Marion Miranda , Sekar Padmini , Williamson Brady , Maloney Thomas , Khandwala Vivek , Dunning Kari , BEHYMER Tyler P , Gilkerson Lee , Reinhart Kelsey , Boyne Pierce E , Yuan Weihong , Flaherty Matthew L , Vagal Achala , Langefeld Carl D. , Woo Daniel
Published: February 2022

Background:
Intracerebral hemorrhage (ICH) patients may appear disabled despite intact cortical spinal tracts (CST). ICH lesions may also vary in volume and location relative to the CST with differential impacts on motor outcome. In this study, we evaluated whether diffusion tensor imaging (DTI) integrity of CST fiber tracking associates with mobility three months post ICH.

Methods:
The Recovery and Outcomes from StrokE (ROSE) Study is a prospective, multi-center study of ICH serially assessed with motor, cognitive, and functional outcomes and MRI/DTI. Outcome data were collected by hospital chart review and interview/exam. Acute MRI images were analyzed by a central neuroimaging core for ICH location, size, intraventricular hemorrhage, and fractional anisotropy (FA) derived from DTI of the CST. Mobility was assessed at 3-month follow-up using the Barthel Mobility Index. We computed single variable logistic regression analyses (outcome = Barthel mobility at 3 months). We also computed a stepwise logistic model, with and without age, sex, and race, including variables that met P<0.1 to best fit.

Results:
There were 76 ICH patients with DTI FA data available for analysis; 61 with complete data for the multivariate model. Poor mobility after ICH (N = 21; 27.6%) was associated with ICH volume, presence of IVH, Glasgow coma score, ipsilesional CST FA, ipsilesional CP FA and CP FA asymmetry index (Table 1). The multivariate model that adjusted for age, sex, and race identified ipsilesional CP FA, admission GCS and presence of IVH as associated with poor mobility at 3 months; notably, log ICH volume was not associated after controlling for CST injury (Table 1).

Conclusions:
The presence of IVH and the GCS score at baseline were associated with poor mobility. In addition, the CP FA asymmetry index was independently associated with poor mobility even after accounting for log ICH volume, suggesting that DTI is informative of outcome beyond classic ICH outcome predictors.
Abstract WMP84: High Morbidity And Mortality Associated With Anticoagulation Prior To Intracerebral Hemorrhage: Propensity Score Analysis Of 10-year Real-world Data
Authors: Ifejika Nneka L , Potter Thomas , Bako Abdulaziz , Pan Alan , Tannous Jonika , Johnson Carnayla , Baig Eman , Meeks Jennifer , Vahidy Farhaan S
Published: February 2022

Introduction:
Anticoagulation for prevention of cardioembolic stroke is safe and effective. However, there is a paucity of data on morbidity and mortality among non-traumatic intracerebral hemorrhage (ICH) patients with history of anticoagulant (AC) use.

Methods:
Using ICD-10 diagnosis/procedure, procedural terminology codes and medications, we identified index ICH events with and without prior AC use from deidentified pooled data; in a network of 50 healthcare organizations (Aug 2011-July 2021). Non adult (<18 years) and the presence of a prosthetic heart valve were excluded. AC and no-AC patients were propensity score (PS) matched for demographic, comorbidity and clinical variables. Match adequacy was assessed by standardized mean difference (SMD). Absolute Risk Difference (RD) and Risk Ratios (RR) with 95% Confidence Intervals (CI) are reported for morbidity [seizure, sepsis, intraventricular hemorrhage or external ventricular drain(IVH/EVD)] and mortality at 5 years post index ICH event in the PS-matched sample.

Results:
Among 193,600 patients with an index ICH event, 171,561 met the inclusion criteria, of whom, 62,578 (36.5%) had prior AC use. Significant pre-match differences in demographic and clinical parameters were observed between the AC and no AC groups (table). PS algorithm generated a 1:1 optimally matched sample (95% SMD reduction) of 21,808 AC and no AC ICH patients each, without significant covariate differences. In the matched sample, the risk of post-ICH seizure, sepsis, IVH/EVD, and mortality were significantly higher in the AC group. RR (CI) for seizure: 1.27(1.22-1.32), sepsis: 1.56(1.46-1.67), IVH/EVD: 1.78(1.66-1.92), mortality: RR (CI) 1.05 (1.02 - 1.09). RD of 5-year death between AC and no-AC groups was 1.3%, compared to a 4.1% RD of seizure, 3.2% RD of sepsis and a 3.7% RD of IVH/EVD.

Conclusion:
In Real World multicenter data, utilization of AC prior to ICH demonstrates significantly high long-term morbidity and mortality.
Abstract WMP92: Time Since Stroke Onset, Quantitative Collateral Score And Functional Outcome After Endovascular Treatment For Acute Ischemic Stroke - Results From The Mr Clean Registry.
Authors: Uniken Venema Simone , Wolff Lennard , van den Berg Sophie , Reinink Hendrik , Luijten Sven , Lingsma Hester , Marquering Henk , Boers Anna , Roos Yvo , Nederkoorn Paul , Majoie Charles B , Dippel Diederik W , Dankbaar Jan , van der Lugt Aad , Van Der Worp H B
Published: February 2022

Background:
In patients with ischemic stroke undergoing endovascular treatment (EVT), time to treatment and collateral status are important prognostic factors. We assessed the relation between time to CT angiography (CTA) and collateral status. Furthermore, we assessed whether collateral status modifies the relationship between onset to recanalization time (ORT) and functional outcome.

Methods:
From the prospective, multicenter MR CLEAN Registry, we included patients with acute ischemic stroke, who had a carotid terminus or M1 occlusion and were treated with EVT in the Netherlands within 6.5 hours of symptom onset. A quantitative collateral score (qCS) was assessed from baseline CTA using an automated image analysis algorithm (Strokeviewer; Nico.lab). Multivariable regression models were used to assess the relationship between time to imaging and the qCS and between ORT and functional outcome (90-day modified Rankin Scale score). An interaction term (ORT * qCS) was introduced in the latter model to test whether qCS modifies this relation.

Results:
We analysed 1813 patients. The median time from symptom onset to CTA was 91 minutes [IQR: 56-150] and the median qCS was 49% [IQR: 25-79]. Longer time to CTA was not associated with qCS (β per 30 minutes, 0.001 [-0.008 - 0.010]). Both a higher qCS (acOR per 10% increase, 1.07 [1.03-1.10], p<0.001) and shorter ORT (acOR per 30 minutes, 1.17 [1.13-1.21], p<0.001) were independently associated with a shift towards better functional outcome. The qCS did not modify the relationship between ORT and functional outcome (p for interaction: 0.28; Figure).

Conclusions:
In patients with ischemic stroke caused by carotid-terminus or M1 occlusion presenting within 6.5 hours of symptom onset, the collateral status is unaffected by time to CTA and the benefit of a shorter ORT is similar across the entire range of collateral scores.
Abstract WP100: Automatic Large Vessel Occlusion Detection On Computed Tomography Angiography Using A 3D Convolutional Neural Network
Authors: Golan Rotem , Cimflova Petra , Ospel Johanna Maria , Bala Fouzi , Elebute Ibukun , Duszynski Chris , Sojoudi Alireza , Souto Maior Neto Luis A , El-Hariri Houssam , Mousavi Seyed Hossein , Menon Bijoy K
Published: February 2022

Purpose:
To validate the performance of a 3D convolutional neural network (CNN) based algorithm i.e. Stroke
SENS
LVO, in automatically detecting the presence of large vessel occlusions (LVO) on computed tomography angiography (CTA) images of the head.

Method:
A total of 400 studies (217 LVO, 183 non-LVO) were used in the analysis. The LVO group includes internal carotid artery (ICA) and m1 segment of the middle cerebral artery (M1-MCA) occlusions; and the non-LVO group includes more distal or posterior cerebral artery occlusions, no occlusions, and hemorrhagic stroke cases. Expert consensus reads were used as reference standard. Performance was evaluated using sensitivity and specificity and corresponding 95% confidence intervals (CI). Additional analysis was performed on several subgroups of interest.

Results:
For detecting LVO, the algorithm achieved a sensitivity of 0.894 [0.853, 0.935] and specificity of 0.874 [0.826, 0.922]. Furthermore, sensitivities of 0.857 [0.779, 0.935] on ICA cases (N=77) and 0.914 [0.868, 0.961] on M1-MCA cases (N=140) were noted; similarly, specificities of 0.891 [0.833, 0.949] on hemorrhagic stroke cases (N=110) and 0.849 [0.767, 0.931] on non-LVO-non-hemorrhage cases (N=73) were noted. Similar performances were observed across stratified datasets based on age, sex, scanner manufacturer and slice thickness when compared to the full cohort.

Conclusion:
Stroke
SENS
LVO demonstrated high accuracy in automatic detection of LVO on a large heterogeneous dataset.
Abstract WP103: Comparison Of Acute Infarct Lesions Between Non-contrast CT, DWI And FLAIR Using Back-to-back Imaging
Authors: Imarhia Frances , Christensen Soren , Lansberg Maarten G , Wang Adam , Heit Jeremy J , Albers Greg
Published: February 2022

Introduction:
Size and location of the acute infarct is a major determinant of stroke outcome and eligibility for therapy. Recently, there have been efforts to train deep learning networks to detect lesions on Non-Contrast CT (NCCT) using concurrent DWI imaging as the gold standard. However, little is known about the radiological correspondence between concurrent NCCT and DWI lesion sizes. We performed an exploratory analysis comparing the stroke lesion volume on acute NCCT to that on DWI and FLAIR images performed shortly after.

Methods:
Population: DEFUSE 3 trial patients scanned 6-16h after last known well with DWI and NCCT <1h apart. NCCT was segmented using an algorithm detecting more than 5% depression compared to the contralateral homologous region. The DWIs and FLAIR were co-registered to NCCT and manually segmented in ITK-Snap.

Results:
Thirteen patients fulfilled inclusion criteria. DWI volumes were (median, [IQR]) 52 mL [39 - 102], FLAIR volumes 35 mL [18 - 66] and NCCT lesion volumes 14 mL [8 - 22]. NCCT lesions were significantly smaller than both DWI and FLAIR, p < 0.001 and p < 0.048. The Dice coefficient was 0.2 [0.1 - 0.3] for FLAIR vs NCCT and 0.3 [0.1 - 0.5] for DWI vs NCCT.

Conclusion:
NCCT lesion volumes were consistently smaller than both DWI and FLAIR lesions although the volumetric agreement with FLAIR lesions was better. Both FLAIR and NCCT are sensitive to influx of parenchymal water and as such may have more similar lesions than DWI imaging which is sensitive to early occurring intraparenchymal displacements. The findings suggest that the training of deep learning networks to detect early NCCT hypodensity should focus on FLAIR or expert outlines drawn directly on the NCCT rather than DWI as the gold standard.
Abstract WP105: Real World Experience With Viz.AI Automated Hemorrhage Detection At A Comprehensive Stroke Center
Authors: Aminian Narsis , Nimjee Shahid M , Shujaat Mohammad T , Heaton Sharon , Lee Vivien H
Published: February 2022

Introduction:
The use of artificial intelligence software to assist in acute ischemic stroke imaging has recently gained widespread acceptance at stroke centers across the country. Viz.AI has added automated detection of suspected hemorrhage (ICH) to its platform, which alerts the clinical team via an iphone application. Real-world performance of Viz.AI ICH detection is limited. We report our single center experience with Viz.AI ICH detection at our academic comprehensive stroke center (CSC).

Methods:
We performed a retrospective review of suspected stroke patients who had a non-contrast CT brain performed as part of a stroke “code” from May 12, 2021 to August 18, 2021. Data was collected on sex, age, Viz.AI ICH alert, and alert times. Radiology determination of hemorrhage on CT brain was considered gold standard and positive. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of Viz.AI ICH compared to control.

Results:
Among 611 consecutive suspected stroke patients with non-contrast CT brain analyzed by Viz.AI ICH, mean age was 63.5 years (range 18 to 95) and 296 (48.4%) were female. Viz.AI ICH autodetection alerted for 82 patients (13.4%). Radiologist review reported 83 patients with hemorrhage. There were 519 true negatives, 9 false positives, 10 false negatives, and 73 true positives. Sensitivity was 87.9% and Specificity was 98.3%. PPV was 89.0% and NPV was 98.1%. The mean time from CT completion to Viz.AI ICH alert notification to the clinical team was 2.03 minutes (range, 1 to 5 minutes).

Conclusions:
In our series of patients evaluated for stroke code at our CSC, Viz.AI automated hemorrhage detection performed with both high sensitivity of (87.9%) and specificity (98.3%) and alerted the clinic teams to suspected ICH within 5 minutes. Further study is warranted to improve processes in acute stroke care.
Abstract WP107: Differences In Automated Perfusion Softwares: Do They Matter Clinically?
Authors: Stanton Robert J , Wang Lily , Smith Matthew , Aziz Yasmin , Zhang Bin , Shirani Peyman , Prestigiacomo Charles , Grossman Aaron W , Vagal Achala , Khatri Pooja
Published: February 2022

Introduction:
Treatment of acute ischemic stroke in the late window changed with the positive results of DAWN and DEFUSE III. Both trials required the use of automated perfusion software for inclusion. Because differences in the predicted core or penumbra between software can lead to differences in eligibility for endovascular thrombectomy (EVT), we sought to compare whether these potential differences would have changed eligibility for EVT by DAWN or DEFUSE III criteria.

Methods:
Patients presenting or transferred to the University of Cincinnati Medical Center between April 23
rd
2019 and July 22
nd
2019 with acute ischemic stroke secondary to large vessel occlusions within the anterior circulation in the extended time window (>6-24 hours) who underwent CT perfusion (CTP) imaging were prospectively tracked. CTP findings, clinical course, age and initial NIHSS were retrospectively reviewed. The primary outcome was EVT eligibility using DAWN or DEFUSE criteria. Secondary outcomes were penumbra (Tmax>6s) and core (CBF<30%) volumes. McNemar test and kappa coefficients were used to assess the agreement in the primary outcome. Intra-class correlation coefficients were used to evaluate the agreement between the software for secondary outcomes.

Results:
Of 46 included patients, the Viz CTP and RAPID software provided discordant EVT eligibility in 5 cases (4 by DEFUSE criteria and 1 by DAWN). By DAWN criteria, agreement was almost perfect between the software packages (kappa 0.96, 95% CI 0.87-1.00, p<0.0001). By DEFUSE III criteria, the two software demonstrated excellent agreement (kappa 0.82, 95% CI 0.65-0.99, p<0.0001).

Discussion:
We observed no difference in eligibility for EVT using either software when both DEFUSE and DAWN criteria were considered. If using only one trial’s criteria, 10.6% of patients would have had differing eligibility for EVT depending on the package used, although this difference did not demonstrate statistical significance.
Abstract WP12: Evolution Of Regional Flair White Matter Hyperintensities After Ischemic Stroke: A Voxel-wise Approach
Authors: Kern Kyle C , Wright Clinton B , Leigh Richard
Published: February 2022

Background:
White matter (WM) degeneration after ischemic stroke may herald post-stroke cognitive decline. FLAIR WM hyperintensity (WMH) reflects tissue injury and accumulates around the infarct and in remote regions. But WMH volumetry is insensitive to regional progression. We compared WMH volumetry to a voxel-wise (VW) approach for detecting FLAIR WMH change longitudinally after stroke.

Methods:
Ischemic stroke patients enrolled in an observational cohort study underwent serial MRI acutely, at 1 month and every 3 months thereafter. Patients with 6 to 12-month follow-up were included. WMH lesion volumes were automatically segmented on serial FLAIR MRI. In the hemisphere contralateral to the infarct after 30 days, we compared longitudinal change in WMH volume to a VW regression of FLAIR signal change over time. Serial FLAIR images were nonlinearly aligned using a T1 intermediate. FLAIR intensities were normalized, corrected for local expansion/contraction, and smoothed. Within voxels identified as lesion at any timepoint, significant WMH change was determined relative to the normal appearing WM and converted to percent of total intracranial volume (TICV).

Results:
22 stroke patients (mean age 73, NIHSS 4, infarct volume 10.3cc) had on average 3 follow-ups over 343 days. In the non-stroke hemisphere, volumetry revealed lesion growth in 12 participants (55%) while VW analysis revealed FLAIR signal increase in 15 (68%). For volumetry, mean lesion increase was 0.01 ± 0.20% of TICV per year while VW FLAIR intensity increased in mean 0.11 ± 0.23% of total intracranial voxels. Volumetric growth was associated with the volume of VW signal increase (Std Beta = 0.51, p = 0.02). In the stroke hemisphere, WMH expansion of peri-infarct tissue, consistent with Wallerian degeneration, was present in 10 participants (45%). WMH regression, consistent with atrophy or infarct cavitation, was present in 14 participants (64%). Stroke hemisphere WMH expansion was associated with higher NIHSS (Std B = 0.58, p = 0.009) while regression was associated with larger infarct volumes (Std B = 0.80, p < 0.001).

Conclusions:
In early chronic stroke, VW longitudinal WMH analysis detects progressive WM degradation with regional variation and may be more sensitive than gross volumetry.
Abstract WP129: Artificial Intelligence For Automated Detection Of Intracranial Hemorrhage (RAPID ICH): Initial Clinical Experience
Authors: Chang Warren , Eisenmenger Laura , Cerejo Russell , Li Charles , Goldberg Michael F
Published: February 2022

Purpose:
Intracranial hemorrhage (ICH) has high morbidity and mortality, but early intervention has been shown to improve clinical outcomes. Several applications have emerged using artificial intelligence (AI) for automated detection of ICH, including RAPID ICH (RICH, iSchemaView, Menlo Park, CA). We present our initial clinical experience with RICH in a busy Level 1 trauma center.

Materials/Methods:
The study was supervised by the local IRB. Emergency department (ED) patients and inpatients (IP) receiving head CTs on the ED scanner at a level 1 trauma center were included. RICH output ("no ICH" or "suspected ICH") was recorded for each exam. Initial interpreting emergency radiologists or neuroradiologists had access to RICH output. Radiology reports reporting ICH were positive and those without ICH were negative. A board certified neuroradiologist reviewed each case with access to the initial report, RICH output, and prior exams. In cases with disagreement between readers, a third reader adjudicated the result and their decision was considered final. Expert reads were used as the gold standard and sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) were calculated.

Results:
1388 patients were included, 1251 from the ED and 137 IP. For the ED patients, 139 had ICH and 1112 did not, where as in the IP cohort, 100 had ICH and 37 did not. RICH demonstrated overall sensitivity of 79% (73% ED, 88% IP), overall specificity of 95% (96% ED, 84% IP), overall PPV of 76% (65% ED, 94% IP) and overall NPV of 96% (97% ED, 72% IP).

Conclusion:
RICH had relatively high sensitivity and very high specificity for ICH, with lower sensitivity/higher specificity in the ED, and higher sensitivity/lower specificity in IP. Active worklist reprioritization allows faster triage of potentially positive studies and earlier intervention potentially improving clinical outcomes, especially in IPs with longer average turnaround times for routine studies.
Abstract WP131: Radiation For Head And Neck Cancer And Risk Of Intracranial Hemorrhage
Authors: Bruce Samuel S , Kamel Hooman
Published: February 2022

Introduction:
Radiation therapy in head and neck cancers has previously been associated with cerebrovascular complications such as aneurysm formation, atherosclerosis, and ischemic stroke. Radiation is also associated with extradural cranial hemorrhagic complications due to weakening of vessel walls and labile hypertension from baroreflex failure. We hypothesized radiation therapy in head and neck cancers would also be associated with intracranial hemorrhage.

Methods:
We performed a retrospective cohort study using inpatient and outpatient claims between 2008-2018 from a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥65 years old with cancer of the oral cavity, nasal cavity, pharynx, or larynx, defined by
ICD-9-CM
and
ICD-10-CM
diagnosis codes, who underwent either radiation therapy or surgical tumor excision, defined by
CPT
codes. Intracranial hemorrhage was defined using
ICD-9-CM
and
ICD-10-CM
diagnosis codes for subarachnoid hemorrhage, intracerebral hemorrhage, and subdural hemorrhage. Cox proportional hazards regression was used to determine the association between radiation therapy and intracranial hemorrhage after adjustment for age, race, atrial fibrillation, coronary artery disease, hypertension, diabetes mellitus, congestive heart failure, chronic kidney disease, tobacco use, and alcohol use.

Results:
Of 15,990 eligible patients, 5,316 (33%) underwent radiation therapy. A total of 568 (3.5%) patients had an intracranial hemorrhage. In unadjusted analysis, radiation therapy was associated with an increased risk of intracranial hemorrhage (HR, 1.72, 95% CI, 1.40-2.10). This association was present after adjustment for age, race, and vascular risk factors (HR, 1.29; 95% CI, 1.04-1.59).

Conclusions:
In a nationally representative cohort of Medicare beneficiaries, radiation therapy for head and neck cancer was associated with an increased risk of intracranial hemorrhage.