bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 140: Impact of Stroke Nurse Education on Stroke Team Activations and Reperfusion Treatments in a Large Regional Stroke Care Network
Authors: Sayles Emily , Sucharew Heidi , Adeoye Opeolu , Kleindorfer Dawn
Published: January 2019

Introduction:
Nurse Education is an important component of successful acute stroke treatment networks. We sought to describe the impact of educational events on the number of acute stroke activations and acute stroke reperfusion therapies, as well as the sustainability of any effects seen within our large network.

Methods:
In 2016, 40 educational events were performed at 14 hospitals within the Greater Cincinnati Stroke Network. Nurses from every unit were encouraged to attend with a focus on the Emergency Department. A one hour presentation titled “Overview and Acute Management of Stroke” was given at each event, which included when to activate the stroke team, identifying the effects of time on the brain during stroke, and strategies for treating patients faster. The number of calls and treatments in the network within the stroke team call log during 2016 were analyzed, partial years before and after 2016 were also analyzed to evaluate 6-months before and after each education event. A segmented Poisson regression model was used to estimate the change in weekly number of calls and treatments immediately after the first education event and the change in the trend over time.

Results:
In 2016, the network received 4273 stroke calls from 39 hospitals, with 457 reperfusion treatments. Among the 14 hospitals that held an education event, we found that the number of calls went up by 40% immediately after the event (p<0.01). Although we also saw a jump in the number of treatments by 46% after, this was not statistically significant (p=0.16). At 6-months, the number of calls was 8% higher than the projected rate without the education (Figure).

Discussion:
Network wide Nurse Education was associated with a significant and profound increase in stroke activations, with a concomitant non-significant increase in reperfusion treatments. This effect was sustained out to 6 months after the educational event. Nurse Education is critical in maintaining networks and improving stroke care delivery.
Abstract 141: Establishing Sensitivity and Specificity of the Maxwell Swallow Screen
Authors: Peters Elizabeth A , Maxwell Rebekah , Leclerc Lucy , Ballard Nancy , VanBrackle Lewis
Published: January 2019

Introduction:
Presence of dysphagia often results in heightened risk of aspiration, pneumonia, and prolonged hospitalization. Dysphagia may contribute to increased disability or death, and contributes to pneumonia, the most frequent medical complication. Thus, valid and reliable diagnostic tools to screen for dysphagia are critical to the well-being of a patient in the acute stage of stroke. The purpose of this research is to establish sensitivity and specificity of the Swallow Screen under investigation (MSS), a screening tool developed by a Speech-Language Pathologist (SLP) for use by nurses in the acute care setting.

Hypothesis:
The MSS is a valid and reliable nursing tool to screen for dysphagia in the stroke population.

Methods:
Retrospective chart reviews were completed over one calendar year on 356 consecutive adult patients with suspected or confirmed diagnosis of stroke. Based on specific inclusion and exclusion criteria, the final sample size was 178. The chart reviews were used to evaluate concurrent validity between the MSS performed by the RN and the Clinical Dysphagia Evaluation (CDE) performed by a SLP. Data were analyzed using SAS version 9.4 based on Clopper-Pearson exact intervals.

Results:
Sensitivity of the MSS (probability that the MSS result is positive given that the SLP result is positive) was calculated as 21/29 = 0.724 (95% confidence interval 0.528 to 0.873). Specificity of the MSS (probability that the MSS result is negative given that the SLP result is negative) was calculated as 144/149 = 0.966 (95% confidence interval 0.923 to 0.989). The positive predictive value for the MSS (21 MSS positive/26 true positive) is 81% and the negative predictive value (144 MSS negatives/152 true negatives) is 95%. Since the implementation of the MSS in 2015, there has been a decrease of HAP in stroke patients with none in 2016 and 2017.

Conclusions:
Despite the Joint Commission mandate for use of swallow screens in the stroke population, there remains no universal standard. In conclusion, based on the sensitivity and specificity identified in the data, the MSS can be deemed a valid and reliable nursing tool to screen stroke patients for risk of aspiration. Secondary analysis revealed a drastic reduction in HAP in stroke patients who were evaluated using the MSS.
Abstract 142: Apoptosis After Psychological Stress is Associated With FoxO1-Mediated Inflammation in the Rodent Brain
Authors: Guo Sichao , Zhu Yuequan , Stone Christopher R , Cosky Eric E , Guan Longfei , Geng Xiaokun , Ding Yuchuan
Published: January 2019

Introduction:
Although the capacity of social stress to cause psychological perturbations is well-known, investigations undertaken in recent years have elaborated a novel field of study: the neurophysiological corollary of these perturbations. This corollary often involves the innate immune system, which can be activated by psychological stress to promote inflammatory pathology. Because psychological stress increases apoptotic cell death in the hippocampus and temporal cortex, we therefore hypothesized that innate immune-induced inflammation may be responsible for this effect. To test this hypothesis, we investigated whether FoxO1, an important regulator of molecular signals in many tissues (including tumor, liver, and brain) that has been found to mediate inflammation following cerebral hemorrhage, could promote inflammation in the context of stress, leading to apoptosis.

Methods:
Six-week-old male C57BL/6J mice were subjected to 10 consecutive days of Acute Social Defeat stress, in which they were placed (individually) for 10 min into the residence of a large male CD1 aggressor mouse, who investigated, attacked, and defeated them. C57BL/6J and CD1 mice were then separated by a transparent partition with stomata for 24 h, allowing the C57BL/6J intruder to receive continued sensory contact from the resident. To quantify the resulting depression, body weight, tail suspension, and sucrose preference were tested daily, along with ELISA-determined serum corticosterone, epinephrine, and IL-6. Protein levels of brain IL-6, TNF-α, FoxO1, apoptotic Bax and anti-apoptotic Bcl2 were measured by Western blot.

Results:
In stress-induced mice, the tail suspension and sucrose preference tests elicited depression-like behavior. Body weight decreased, while serum corticosterone and epinephrine levels increased. Brain IL-6 and TNF-α, as well as serum IL-6, were also significantly upregulated in this group. Brain expression of FoxO1 was increased, protein levels of Bax were upregulated, and Bcl2 was downregulated.

Conclusion:
Acute social stress promoted depression and brain apoptosis, in association with an inflammatory reaction. Our results suggest that these psychological stress-mediated changes were caused by increased FoxO1 expression.
Abstract 144: The Association of Statin Pretreatment With Collateral Circulation and Final Infarct Volume in Patients With Acute Ischemic Stroke Due to Large Vessel Occlusion
Authors: Malhotra Konark , Safouris Apostolos , Goyal Nitin , Arthur Adam , Liebeskind David S , Katsanos Aristeidis H , Sargento-Freitas João , Ribo Marc , Molina Carlos , Chung Jong-Won , Bang Oh Young , Cheema Ahmed , Uchino Ken , Alexandrov Andrei V , Tsivgoulis Georgios
Published: January 2019

Introduction:
Observational study data suggest that statin pretreatment (SP) could be associated with better outcomes in acute ischemic stroke (AIS) by improving collateral circulation. In turn, adequacy of collateral circulation is known to improve neurological outcome through the reduction of final infarct volume (FIV) after an AIS. We sought to evaluate the association of SP on collateral circulation status and FIV in patients with AIS due to large vessel occlusion.

Methods:
We performed a systematic review and meta-analysis on MEDLINE and SCOPUS databases to identify all studies reporting on collateral circulation status and/or FIV, according to SP history. We contacted authors of eligible for inclusion studies to provide data of interest, in case they were not available in original publications. Good collateral status was defined on angiography by scores 3-4 according to the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system or collateral pial circulation scores of 0-2. In eligible studies we also estimated the standardized mean differences (SMDs) on the FIV measurements according to SP history. All analyses were performed under the random-effects model, while heterogeneity was assessed with the I
2
and Cochran Q statistic.

Results:
We identified 8 eligible study protocols (972 AIS patients; 32% with SP history). Patients with history of SP had significantly lower FIV (SMD=0.21, 95%CI: 0.01-0.41, p=0.04; Figure A) compared to the rest. Moreover, SP tended to be associated with good collateral status (odds ratio=1.45, 95%CI: 0.92-2.29, p=0.11; Figure B) compared to patients without SP history. No evidence of heterogeneity (I
2
<35%) was detected in both analyses.

Conclusion:
SP appears to be associated with decreased FIV after AIS, possibly due to more favorable collateral circulation. This observation deserves further validation in large-scale, prospective cohort studies.
Abstract 145: Advanced Neuroimaging in Stroke Patient Selection for Mechanical Thrombectomy: A Systematic Review and Meta-analysis
Authors: Tsivgoulis Georgios , Katsanos Aristeidis H , Schellinger Peter D , Köhrmann Martin , Caso Valeria , Palaiodimou Lina , Magoufis Georgios , Arthur Adam , Fischer Urs , Alexandrov Andrei V
Published: January 2019

Introduction:
There is clinical equipoise regarding the use of advanced imaging for selecting acute ischemic stroke (AIS) patients eligible for mechanical thrombectomy (MT) during the first 6 hours from symptom onset. However, accumulating evidence indicates that advanced neuroimaging represents an invaluable and time independent prognostic factor.

Methods:
We performed a systematic review and meta-analysis of available randomized clinical trials (RCTs) to evaluate the impact of patient selection with advanced neuroimaging on the 3-month: 1. functional independence (FI, mRS: 0-2), 2. favorable functional outcome [FFO, modified Rankin Scale scores (mRS): 0-1], 3. all-cause mortality and 4. functional improvement (assessed with ordinal analysis of the mRS-scores).

Results:
Among the 10 eligible RCTs (1979 total patients, mean age: 67 years), 5 studies reported the use of advanced imaging. Studies using advanced neuroimaging showed higher treatment effects of MT on 3-month FI (OR=3.79, 95%CI: 2.71-5.28 vs. OR=1.76, 95%CI: 1.39-2.24; p for subgroup differences<0.001), FFO (OR=3.16, 95%CI: 1.94-5.14 vs. OR=1.75, 95%CI: 1.30-2.34; p for subgroup differences=0.04) and functional improvement (cOR=2.77, 95%CI: 2.04-3.76 vs. 1.60, 95%CI: 1.32-1.95; p for subgroup differences: 0.003) compared to studies using conventional neuroimaging. Including only studies in the early (0-8hrs) time window advanced imaging selection was associated with better 3-month FI rates (p for subgroup differences: 0.04) compared to conventional imaging selection. No difference in the mortality (p for subgroup differences: 0.27) and sICH rates (p for subgroup differences 0.93) was found between the two groups. No evidence of heterogeneity was documented in all the aforementioned subgroups (I
2
<30%, p for Cochran Q>0.17 for all analyses).

Conclusions:
Our findings indicate that AIS patient selection for MT based on advanced neuroimaging appears to be associated with improved clinical outcomes, including lower mortality rates. The use of advanced neuroimaging for both the selection and prediction of prognosis for MT candidates should not depend on the elapsed time from symptom onset.
Abstract 150: A Phase II Multicenter Randomized Controlled Trial of Tiopronin for Aneurysmal Subarachnoid Hemorrhage
Authors: Ironside Natasha , Christophe Brandon , Bruce Samuel S , Robison Trae , Yoh Nina , Cremers Serge , Landry Donald , Hoh Brian , Kim Louis , Claassen Jan , Connolly Edward S
Published: January 2019

Introduction:
Subacute symptomatic neurological decline is a significant and preventable contributor to patient morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). 3-Aminopropanal (3-AP) is a potent neurotoxin that is upregulated in the setting of cerebral ischemia. Targeted neutralization has achieved a neuroprotective effect in preclinical models. This phase II trial evaluated the efficacy of Tiopronin administration in reducing 3-AP levels in patients with aSAH.

Methods:
We designed a prospective, randomized, double-blind, placebo-controlled clinical trial that was conducted in three centers in the United States. 60 patients were enrolled and assigned to receive Tiopronin or placebo in a 1:1 ratio from enrolment until the earlier to occur of post-bleed day 14 or hospital discharge. Patients received a total of 3 grams daily, in 3 divided doses. The primary efficacy endpoint was the change in serum and/or cerebrospinal fluid (CSF) 3-AP from enrolment to study drug discontinuation.

Results:
Of the 60 enrolled patients, 29 (97%) in the treatment arm and 27 (93%) in the control arm received more than one dose of the study drug. A greater relative reduction in serum 3-AP level was observed in the treatment arm (adj Beta=-0.689, 95% C.I.=-2.730, -0.008; p=0.049). This was most apparent, but did not reach significance, in patients with grade IV-V aSAH (adj Beta=-0.808; 95% C.I.=-3.872, 0.167; p=0.067). No difference in the change in CSF level was observed (adj Beta=0.048, 95% C.I.=-2.334, 2.589; p=0.903). Pre-specified adverse events led to early cessation of treatment for four patients in the treatment arm, and two in the control arm.

Conclusion:
Tiopronin attenuated the accumulation of serum 3-AP, providing the first translational evidence for the use of 3-AP antagonists in aSAH. Further investigation to evaluate for a dose-response relationship in Tiopronin’s ability to cross the blood-brain barrier is recommended. 
Abstract 151: Physiologic Predictors of Collateral Circulation and Infarct Growth in Setting of Anesthesia During Thrombectomy: Detailed Analysis of the GOLIATH Trial
Authors: Raychev Radoslav I , Liebeskind David S , Brown Scott , Arnaudov Dimiter , Yoo Albert , Jeffrey Saver , Z Simonsen Claus
Published: January 2019

Introduction:
Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion and may be affected by multiple variables during sedation for endovascular therapy (EVT). Identification of potentially modifiable physiologic predictors of collateral circulation will help to refine the most optimal anesthetic strategy in clinical practice and future trials.

Methods:
We conducted detailed analyses of the GOLIATH database to identify 1) predictors of collateral circulation grade and 2) infarct growth at 24h. Angiographic collaterals immediately prior EVT were graded by two investigators, followed by consensus adjudication. We also modified the ASITN collateral scale by dividing grade 2 in two separate categories: 2- (persistent filling defect in >50% of the ischemic territory) and 2+ (<50% of the territory) and sought to determine its impact on clinical outcome and 24h infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth.

Results:
Collaterals were evaluable in 62% (80/128) of analyzed patients, including grades 1 (n=9), 2- (n=19), 2+ (n=31), 3 (n=21). Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth (figure 1). There was no correlation between collaterals and outcome. Among all analyzed variables [Age, NIHSS, ASPECTS, HTN, DM, time to groin, end tidal CO2 levels, general anesthesia, Propofol dose, Phenylephrine dose, mean arterial pressure (MAP) drop < 70 mmhg ], the most significant predictor of infarct growth at 24h was Phenylephrine dose (beta 6.13; p=0.026), and the most significant predictor of collateral grade was MAP < 70 mmhg (OR 0.34; p = 0.044).

Conclusions:
ASITN grade 2-/+ may be useful as distinct categories for collateral grading. Higher phenylephrine dose is a strong predictor of infarct growth, while lower MAP strongly correlates with worse angiographic collaterals during sedation for EVT.
Abstract 152: Thrombectomy With Conscious Sedation Increases Functional Independence Compared to General Anesthesia: A DEFUSE-3 Post-hoc Analysis
Authors: Dornbos David L , Powers Ciaran J , Mlynash Michael , Gulati Deepak , Torbey Michel , Nimjee Shahid M , Lansberg Maarten G , Marks Michael P
Published: January 2019

Introduction:
The optimal method of patient sedation for mechanical thrombectomy in large vessel occlusion, particularly in the delayed time window, remains unknown. We evaluated the endovascular arm patients of the DEFUSE-3 trial for outcome differences between general anesthesia (GA) and conscious sedation (CS). While CS was the suggested method in the trial, the choice was ultimately left to the discretion of the treating interventionalist.

Methods:
A post-hoc analysis of patients enrolled in the DEFUSE-3 study was performed to assess differences in functional independence (modified Rankin scale of 0-2) at 90 days comparing patients undergoing GA to CS. The groups were also compared for baseline clinical and imaging characteristics and procedural process measures. Statistical analyses were performed using the Mann-Whitney U test, χ
2
-test, and logistic regression analysis.

Results:
Among patients undergoing thrombectomy, 26 (28%) utilized GA, while 66 (72%) underwent CS. Baseline demographics, clinical and radiologic characteristics were similar between the groups. Functional independence at 90 days (Figure 1) was observed in 53% of patients undergoing CS, compared to 23% of those receiving GA (adjusted-odds ratio of 0.27 (0.08-0.93), p=0.037). Patients undergoing CS had better NIHSS scores at 24 hours compared to GA (8 versus 15.5, p=0.032), but not at discharge (4 v 8, p=0.133). Importantly, CS yielded a faster time from arrival in the angiography suite to femoral puncture (median 14 minutes, interquartile range (IQR) 9-18) compared to GA (18 min, IQR 12-22, p=0.0497). Time from femoral puncture to reperfusion was also shorter with CS (median 36 min, IQR 25-51) than with GA (48 min, IQR 32-83, p=0.004).

Conclusions:
Patients undergoing thrombectomy between 6 to 16 hours following stroke onset exhibit improved functional independence at 90 days when treated with CS as compared to GA. This difference may be mediated by faster time to reperfusion in this cohort.
Abstract 153: Blood Pressure and Outcome After Mechanical Thrombectomy: A Multicenter Study
Authors: Anadani Mohammad , Orabi Yser , Alawieh Ali , Goyal Nitin , Pandhi Abhi , Alexandrov Andrei , L.Maier Ilko , Psychogios Marios-Nikos , Inamullah Ovais , Rahman Shareena , Keyrouz Salah , A Giles James , Allen Michelle , Q.Wolfe Stacey , Kan Peter , A.Nascimento Fábio , M. Spiotta Alejandro
Published: January 2019

Introduction:
Hypertension is a known predictor of poor outcome and hemorrhagic complications after ischemic stroke. However, the effect of blood pressure (BP) on outcome of those undergoing mechanical thrombectomy and especially after successful recanalization is not well understood. In this study, we investigated the association between BP parameters and outcome measures after successful recanalization with MT.

Methods:
This was a retrospective, multicenter study, involving 7 comprehensive stroke centers, of patients with acute ischemic stroke due to large vessel occlusion who achieved successful recanalization with MT. Systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were obtained at frequent intervals (at least hourly) for each patient in the first 24 hours following MT. Outcome measures included 90 day-modified Rankin Scale (mRS), 90-day morality, and symptomatic intracerebral hemorrhage (sICH). Successful recanalization was defined as TICI 2b-3, and sICH as any hemorrhage associated with > 4 points increase in NIHSS. A mixed logistic model was used to identify predictors of functional and hemorrhagic outcomes.

Results:
A total of 989 patients were included, of whom 453 (45.8%) achieved good outcome, defined as an mRS of 0-2. Mean, and maximum SBP were higher in the poor outcome group (131.6 +15 vs. 127 +14.3; p <0.001, and 166± 24.7 vs. 158±24.3; p<0.001, respectively). There was no significant difference in the rest of BP measurement between the two groups. With respect to hemorrhagic complications, 40 (4.2%) patients develop sICH after MT. SBP, DBP and MAP were higher in sICH group. Table 1 summarizes multivariable analysis results.

Conclusion:
Higher blood pressure was associated with hemorrhagic complications, and worse functional outcome following successful mechanical thrombectomy.
Abstract 156: Effect of Air Pollution on Intracranial Atherosclerosis: Role of Inflammatory Response and Oxidative Stress
Authors: Guan Longfei , Geng Xiaokun , Cosky Eric E , Ding Yuchuan
Published: January 2019

Introduction:
Air pollution, especially particulate matter with an aerodynamic diameter less than 2.5 μm (PM2.5), has become a significant public health concern in the world. Epidemiological studies have demonstrated that PM2.5 exposure is associated with many diseases including stroke, in which intracranial atherosclerosis (ICA) is largely involved. This study investigated whether inhalation of PM2.5 caused ICA and whether omega-3 fatty acids (O3FA) attenuated the development of ICA.

Methods:
Sprague-Dawley rats were under filtered air (FA) or PM2.5 exposure with normal chow diet (NCD), high-cholesterol diet (HCD) with or without O3FA (5 mg/kg/day by gavage) for 6 or 12 weeks. Blood lipids were measured. ICA was determined by lumen diameter and thickness of the middle cerebral artery (MCA). Inflammatory markers, interleukin 6 (IL-6), tumor necrosis factor alpha (TNF-α), monocyte chemoattractant protein-1 (MCP-1), interferon gamma (IFN-γ), vascular cell adhesion molecule 1 (VCAM-1) and inducible nitric oxide synthase (iNOS) were assessed by RT-PCR for mRNA and Western blot for protein expression. Reactive oxygen species (ROS), malondialdehyde (MDA), superoxide dismutase (SOD) activity, NADPH oxidase (NOX) activity, mRNA levels of
Nrf2, HO-1, NQO-1
and protein level of NOX subunit gp91 were determined as oxidative profiles.

Results:
Twelve but not 6 week exposure significantly increased TG in normal diet, while PM2.5 enhanced all lipid profiles (TG, LDL and CHO) after both 6 and 12 week exposure with HCD. PM2.5 exposure for 12 weeks significantly induced MCA narrowing and thickening, in association with the enhanced expression of inflammatory cytokines (IL-6, TNF-α, MCP-1 and IFN-γ), VCAM-1 and iNOS. PM2.5 exposure for 12 weeks significantly increased ROS and MDA level, up-regulated
Nrf2, HO-1, NQO-1
mRNA levels and gp91 protein level, while decreased SOD activity especially in HCD group. O3FA significantly attenuated PM2.5 induced vascular alterations, as well as inhibiting inflammatory response and oxidative injury.

Conclusion:
PM2.5 exposure for 12 weeks aggravates ICA in a dietary model, which was mediated by vascular inflammation and oxidative stress. O3FA dietary supplementation prevents ICA development in cerebral vessels.
Abstract 168: Detection of Stroke Using Highly-Parallel Profiling of the Circulating Antibody Pool
Authors: O'Connell Grant C , Stafford Phillip , Walsh Kyle B , Adeoye Opeolu , Barr Taura L
Published: January 2019

Quick and accurate recognition of stroke during triage improves the probability of positive outcome, however the tools currently available to clinicians for prehospital and early in-hospital diagnosis of stroke are limited. The peripheral immune system is intricately involved in stroke pathology, and thus may be targetable for the development of immunodiagnostics. In this study, we sought to determine whether the circulating antibody pool is altered early in stroke, and whether such alterations could be leveraged for diagnosis. 100 uL of peripheral whole blood was sampled from 19 ischemic stroke patients, 17 hemorrhagic stroke patients, and 20 stroke mimics upon stroke team referral. A custom-fabricated high-density peptide array comprised of 125,000 unique probes was used to assess the binding characteristics of blood-borne antibodies, and a random forest-based approach was used to select a parsimonious set of probes with an optimal ability to discriminate between groups. The coordinate antibody binding intensities of the top 17 probes identified in our analysis displayed an ability to differentiate between stroke patients and stroke mimics with 92% sensitivity and 90% specificity, as well as detect hemorrhage with 88% sensitivity and 87% specificity, as determined using a same-set cross-validation. Our findings suggest that stroke-associated alterations in the circulating antibody pool may have clinical utility for diagnosis during triage, and that such a possibility warrants further investigation.
Abstract 169: Rural Hospitals in Telestroke: How Effective are On-Site Mock Drills and Community Education on Stroke Awareness?
Authors: Brown Aliza T , Onteddu Sanjeeva , Nalleballe krishna , Joiner Renee , Benton Tina , Lowery Curtis
Published: January 2019

Background:
Mock drills of stroke triage care is an essential training component of most telestroke programs. Another potential component for telestroke programs is community stroke awareness education. While stroke-mocks improve the timeliness and care in rural spoke emergency departments (ED), community stroke awareness education may also improve treatment. Mocks and community education information was evaluated in the Arkansas Stroke Assistance through Virtual Emergency Support (AR SAVES) telestroke program. Correlations were made with mean Door to ED physician (D2MD) time and door-to-needle (D2N) Alteplase time and administration numbers (#Alteplase) and consult numbers (#Consults).

Hypothesis:
Total number of mocks (#Mocks) and community education events (#Community-events) will independently increase #Consults and #Alteplase, and improve the D2MD and D2N time.

Methods:
We retrospectively reviewed 2017 spoke hospital data from AR SAVES, the largest statewide telestroke program. The total number of #Mocks, #Community-Events was comparatively analyzed using regression analysis for D2MD, D2N, #Consults and #Alteplase.

Results:
Data from 51 spoke sites and 1,002 consults, indicated #Mocks were positively correlated to the D2MD time (R=0.31; p=0.03) and the #Alteplase (R=0.28; p=0.04); however, increasing the #Mock sessions did not influence the D2N time or the #Consults (p=NS). Community-Events were significantly associated with #Consults (R=0.48; p=0.0004) and #Alteplase (R=0.47; p=0.0006); however not to D2MD time or D2N time (p=NS).

Conclusions:
Mocks and Community stroke awareness education played crucial roles in the AR SAVES program improving #Consults and #Alteplase administrations. Both education components are warranted for telestroke programs.
Abstract 171: Stroke Identification by Emergency Medical Services: Determinants and its Impact on In-Patient Care
Authors: Robinson Serena N , Ido Moges S , Bayakly Rana
Published: January 2019

Background:
Recognizing acute stroke by Emergency Medical Services (EMS) is critical for timely care. We assessed the accuracy and determinants of stroke diagnosis by EMS and evaluated its impact on stroke patient care in Georgia.

Methods:
Data from the Georgia Coverdell Acute Stroke Registry on 6,586 clinically diagnosed and hospitalized acute stroke patients were linked to the 2016 Georgia EMS Information System. Accuracy of EMS recognition of clinically diagnosed stroke (sensitivity) was estimated using hospital diagnosis as the gold standard. Multivariable logistic regression was applied to identify determinants of stroke diagnosis and assess its impact on stroke patient care using door-to-imaging time.

Results:
EMS sensitivity of identifying acute stroke was 48.6%. In a multivariable model, considering ischemic stroke patients only, correct EMS diagnosis was positively associated with emergency medical dispatch (EMD) report of stroke (OR=4.67; 95%CI: 3.96-5.50); severity of stroke as measured by NIH stroke scale score (OR
5-14 Vs. 0-5
=2.17, 95%CI: 1.83-2.57; OR
15+ Vs. 0-5
=4.23, 95%CI: 3.37-5.32); clinical signs of slurred speech (OR=2.35, 95%CI: 2.00-2.75); and weakness of the extremities (OR=1.57, 95%CI: 1.33-1.85). Correct diagnosis was negatively associated with altered level of consciousness (OR=0.56, 95%CI: 0.46-0.70). Patients assisted by EMS with higher level of certification had higher odds (OR=1.36, 95%CI: 0.94-1.97) of being identified as having stroke than those attended by emergency medical technicians with basic training. Patients identified as having stroke by EMS had 3.78 times higher odds (95%CI: 3.01-4.75) of receiving imaging within 25 minutes of hospital arrival than those who were missed by EMS.

Conclusion:
Pre-hospital identification of acute stroke improves in-hospital care; however, about half of stroke patients transported by EMS in 2016 were not identified in the field. Identification of acute stroke is associated with EMS personnel level of certification, EMD’s report of stroke, and presenting symptoms of the disease and its severity. Thus, it is essential to improve EMDs level of understanding of stroke, enhance EMTs skill in stroke identification for swifter cinical care and better patient outcomes.
Abstract 173: Effect of a Regional Telestroke Program on Door-to-Needle Time and Clinical Outcomes
Authors: Nguyen Huynh Mai N , Hatfield Meghan , Lee Catherine , Flint Alexander C , Klingman Jeffrey
Published: January 2019

Background:
Published data suggest that the faster acute stroke patients are treated with IV alteplase the better they do post discharge. Telestroke allows community hospitals to access stroke expertise in the management of acute stroke patients. In a real-world practice setting, we assessed the influence of a regional standardized telestroke program among community hospitals on door-to-needle (DTN) time and clinical outcomes.

Methods:
In January 2016, a new standardized acute telestroke program for 21 stroke centers in an integrated healthcare system was launched. It included immediate evaluation by a stroke neurologist via video, an expedited IV alteplase treatment program, rapid CT angiographic investigation, and expedited transfer and treatment for patients with large vessel occlusion. We compared patient characteristics, DTN times, length of stay (LOS), discharge outcomes, and 90-day mortality between those treated with IV alteplase pre- (July 2013 to June 2015) to post-telestroke program (January 2016 to December 2017).

Results:
Post-implementation of the telestroke program, more patients were treated with alteplase (Table). Median DTN time and LOS were shorter. A greater percentage of patients were discharged home (57.3% in post-telestroke vs. 12.1% in pre, p<0.001). In-hospital mortality was higher in post-telestroke compared to pre. However, symptomatic hemorrhage rates were not significantly different, at 4.5% in 2014 pre-EXPRESS, 4.3% in 2016 and 3.2% in 2017 post-EXPRESS. In addition, 90-day mortality was not different between pre- and post-telestroke (Table).

Conclusions:
Implementation of a regional standardized telestroke program in a community setting increased utilization of alteplase, improved DTN time, decreased length of stay and significantly increased the chances of patients going home. Further analyses are needed to understand the significant contributing factors to the success of this program.
Abstract 175: Faster Prehospital Workflow in the Melbourne Mobile Stroke Unit Halves Onset to Reperfusion Therapy
Authors: Zhao Henry , Coote Skye , Langenberg Francesca , Easton Damien , Bent Lindsay , Foster Shane , Stephenson Michael , Smith Karen , Bernard Stephen , Bladin Christopher , Cadilhac Dominique , Thijs Vincent , Coulton Bronwyn , Brooks Mark , Asadi Hamed , Ng Felix , Desmond Patricia , Mitchell Peter , Yan Bernard , Campbell Bruce C , Parsons Mark , Donnan Geoffrey A , Davis Stephen M
Published: January 2019

Background:
The Melbourne Mobile Stroke Unit (MSU) utilises a specialised ambulance with on-board CT scanner and multidisciplinary team to provide on-scene imaging, treatment and triage for central Melbourne, Australia. We describe the operational impact of the MSU on stroke onset to treatment time for acute reperfusion therapy.

Methods:
Data from the first 6 months of operation were collected for all patients receiving reperfusion therapy from November 2017. Workflow times were compared to contemporary published Australian data and ambulance travel times were derived using a validated Google Maps algorithm.

Results:
In the first 6 months of operation, the Melbourne MSU provided prehospital thrombolysis (tPA) to n=28 patients (39% of ischemic stroke<4.5h) and directed n=17 patients (24% of infarcts <6hrs) for endovascular thrombectomy (EVT), of which 6/17 (35%) required bypass of the closest non-EVT hospital. Figure 1 shows workflow times for thrombolysis and thrombectomy bypass compared to historical controls. The overall median onset-to-tPA for MSU patients was 101 mins compared to the Australian metropolitan median of 150 mins. Despite a median travel time of 15 mins to the nearest stroke centre, the calculated time saving to start of tPA was 30-60 mins. Prehospital notification for EVT allowed median hospital arrival-to-groin puncture time of 33 mins compared to historical values of 54 mins. MSU diagnosis and bypass to an EVT hospital conservatively reduced EVT delay by 60-90 mins.

Discussion:
Prehospital treatment and triage using the Mobile Stroke Unit in metropolitan Melbourne resulted in substantially faster commencement of reperfusion therapy. First medical contact to treatment times were approximately halved for thrombolysis and patients requiring bypass for endovascular thrombectomy. Future research will determine the effect of earlier treatment on patient outcomes and cost-effectiveness analysis.
Abstract 178: Correlation between Modified Rankin Scale and Quality of Life in DEFUSE 3
Authors: Polding Laura C , Tate William J , Mlynash Michael , Marks Michael P , Heit Jeremy J , Kemp Stephanie , Albers Gregory W , Lansberg Maarten G
Published: January 2019

Background:
The relationship between the modified Rankin Scale (mRS) and quality of life in stroke patients treated in late time windows (6-16 hours) has not been explored. Using data from the randomized DEFUSE 3 trial, we aimed to assess the strength of the correlation between mRS at day 90 and quality of life outcomes.

Methods:
Neuro-QoL is a measurement tool designed to assess quality of life (QoL) outcomes in adults with neurologic disorders. In DEFUSE 3, Neuro-QoL short forms were administered at day 90 to assess quality of life in four domains: mobility, ability to participate in social roles and activities, cognitive function, and depression. Raw scores were transformed to T-scores, which calibrates the scores to the distribution in the US general adult population with a mean score of 50 and SD of 10. For consistency among domains, the distribution of depression T-scores was inverted across the mean such that higher scores reflect better outcomes. We assessed the strength of the correlation between mRS and each domain using the Spearman rank correlation coefficient (Rs
2
) and tested for unidirectional trend using the Jonckheere-Terpstra test.

Results:
In DEFUSE 3, 146 patients were alive at day 90. Of these, 128 completed all four quality of life forms, 10 did not complete any of the forms, and 8 completed a subset of the forms. In each domain, quality of life outcomes worsened with increasing mRS (p<0.001 for all; see figure). The mRS accounts for a high degree of the variability in mobility (Rs
2
=0.82) and a moderate degree in social participation (Rs
2
=0.62), yet accounts only for a low degree in cognition (Rs
2
=0.31) and depression (Rs
2
=0.19).

Conclusion:
The modified Rankin Scale fails to fully capture patients’ mental health and cognitive outcomes, which are critical measures of well-being. These results warrant assessment with quality of life tools focused on mental health and cognition in future stroke trials.
Abstract 179: Bending the Curve: Are We Labelling More Low-risk People as TIA or Has Modern Medical Management of TIA Reduced Stroke Recurrence Over Time?
Authors: Wang Ryan , Lindsay Patrice , Goia Cristina , Kapoor Arunima , Swartz Richard H
Published: January 2019

Background:
Management of transient ischemic attacks (TIA) in specialized stroke centres and prevention clinics have been shown to decrease stroke recurrence and mortality. The impact of these services on a population level are unknown. We aimed to analyze whether modern medical management of TIA has decreased the rate of stroke recurrence and mortality over time in Ontario.

Methods:
Administrative data from the Canadian Institute for Health Information’s Discharge Abstract Database (DAD) and National Ambulatory Care Reporting System (NACRS) database 2003-2015 were analyzed and rates of stroke recurrence and mortality were calculated.

Results:
From 2003 to 2015 in Ontario, there were an increasing number of discharges from emergency departments (ED) and a decreasing number of discharges from hospitals. Linear regressions of stroke recurrence at 24 hours, 48 hours, day 7, 30, 90, 180, and 1 year after a TIA showed significantly faster decline between 2003-2015 (p <0.01). Overall stroke recurrence at 1 year decreased from 5.8% to 2.7% between 2003 and 2015, a rate greater than could be explained just from increasing numbers of people labelled as TIA. From 2003-2015, mortality after ED discharge following a TIA decreased from 1.3% to 0.3% (p<0.001), also a greater decline than expected.

Interpretations:
There is increasing outpatient management of TIAs in Ontario. The observed decline in stroke recurrence was greater than can be explained by referral bias alone, and the increasingly negative slopes of these lines from 24 hours to 1 year suggest a cumulative benefit of improved TIA management over time rather than just increased labelling of low-risk patients. On a population-level, stroke recurrence and mortality after TIA have declined from 2003 to 2015 with a province-wide system of organized stroke care. In contrast to other studies that have shown reduced stroke recurrence and mortality at specialized centres, this study demonstrates the impact of these programs at a population level.
Abstract 18: Genetically-Determined Cholesterol Levels are Associated with Risk of Spontaneous Intracerebral Hemorrhage
Authors: Kirsch Elayna P , Leasure Audrey C , Matouk Charles C , Sansing Lauren H , Crawford Katherine , Kourkoulis Christina , Woo Daniel , Rosand Jonathan , Anderson Christopher D , Sheth Kevin N , Falcone Guido J
Published: January 2019

Background:
Observational studies found an inverse correlation between cholesterol levels and risk of spontaneous intracerebral hemorrhage (ICH). We investigated whether the cumulative burden of known genetic risk loci for cholesterol levels influences the risk of sustaining an ICH.

Methods:
We utilized genetic risk scores (GRSs) to model the cumulative burden of cholesterol-related common genetic variants (CGVs). GRSs were constructed using an approach that allows the implementation of GRS analysis by combining summary statistics from GCVs known to influence the exposure (cholesterol levels) and outcome (ICH) of interest. Summary statistics were identified and abstracted using the Cerebrovascular Disease Knowledge Portal. For cholesterol levels (derivation dataset), we abstracted summary statistics for independent CGVs associated with cholesterol levels at p<5x10
-5
in a large genetic meta-analysis that included data from Kaiser Permanente, UK Biobank and Global Lipids Genetics Consortium. We excluded CGVs at
CETP
, a cholesterol-related locus known to modify ICH risk. For ICH (testing dataset), we abstracted summary statistics from a meta-analysis of 5 genetic studies.

Results:
We identified 711 CGVs associated with cholesterol levels in the derivation dataset (study population 76,627, mean age 56 [SD 9], female sex 44,856 [59%]). Summary statistics were available for 468 of these CGVs in the ICH testing dataset (study population 3,026, mean age 67 [SD 10], female sex 1,362 [45%]). The GRSs for total cholesterol (OR 0.87, 95%CI 0.73-1.01;
p
=0.04), LDL (OR 0.78, 95%CI 0.65-0.91;
p
=0.0002) and triglycerides (OR 1.18, 95%CI 1.04-1.32;
p
=0.02) were associated with risk of all ICH. After stratifying by location, the association became stronger for deep ICH and total cholesterol (OR 0.77, 95%CI 0.61-0.93;
p
=0.001) and LDL (OR 0.70, 95%CI 0.55-0.85;
p
=8x10
-6
). Only the triglycerides-based GRS was associated with lobar ICH (OR 1.26, 95%CI 1.08-1.44;
p
=0.01).

Conclusions:
The cumulative burden of cholesterol-related mutations is associated with risk of ICH. Our results point to an inverse correlation between genetically-determined total cholesterol and LDL levels and ICH risk. These associations are stronger for deep ICH.
Abstract 180: Carotid Artery Stiffness and the Development of White Matter Hyperintensities Over a 20-Year Period: A Secondary Analysis of the ARIC Study
Authors: de Havenon Adam , Majersik Jennifer , Alexander Matthew , Baradaran Hedieyh , McNally Scott , Rost Natalia
Published: January 2019

Introduction:
Arterial stiffness is a biomarker of cerebrovascular disease risk. Prior reports have shown an association between concurrent measurements of carotid artery stiffness and white matter hyperintensity (WMH).

Hypothesis:
Carotid artery stiffness will accurately predict WMH burden on MRI performed 20 years later in the Atherosclerosis Risk in the Community (ARIC) study.

Methods:
We included ARIC patients with carotid stiffness on ultrasound at Visit 2 (1990-1992) and brain MRI with volumetric WMH at Visit 5 (2011-2013). The primary outcome is WMH in cm
3
and the secondary is WMH as a percentage of intrapatient total brain volume. The predictor is carotid stiffness, which is the inverse of the validated ultrasound measurement of Arterial Distensibility, divided into quintiles.

Results:
Inclusion criteria were met by 1,404 patients (41% male), aged 55.6±5.3 years at the ultrasound and 76.3±5.4 years at the MRI. Carotid stiffness was highly correlated with WMH volume and WMH volume after adjustment for total brain volume (Table 1). This association persisted in a multivariate model (Table 2) and is linear in nature (Figure 1).

Conclusion:
Carotid stiffness is an accurate predictor of WMH volume measured 20 years later. This biomarker could prove informative for future studies seeking to delay WMH progression.
Abstract 182: Association of High-Degree Intracranial Stenosis With Risk of Vascular Events Among Stroke-Free Individuals: Results From the Northern Manhattan Study (nomas)
Authors: Gutierrez Jose , Gil Guevara Andrea , Khasiyev Farid , Di Tullio Marco , McLaughlin Consuelo , Rundek Tatjana , Wright Clinton B , Sacco Ralph , Elkind Mitchell S
Published: January 2019

Background:
Individuals with stroke due to high-degree intracranial stenosis (i.e. > 70% by WASID criteria have a high 1-year risk of stroke recurrence. Whether high-degree intracranial stenosis in stroke-free individuals increases the risk of vascular events is less certain. We hypothesized that high-degree intracranial stenosis in stroke-free individuals is associated with risk of death and vascular events.

Methods:
Participants in the population-based Northern Manhattan Study (NOMAS) with available time-of-flight MRA were included in this study. We rated intracranial stenosis using WASID criteria and defined high-degree intracranial stenosis if the lumen was reduced by > 70% in the anterior, middle, or posterior cerebral arteries or in the basilar, vertebral or intracranial carotid arteries. Death and vascular events were prospectively ascertained, blinded to stenosis status. Stroke outcomes were subtypes according to the Trial of Organon in Acute Stroke Trial (TOAST) criteria.

Results:
We included 1,206 NOMAS participants (mean age 70.6±9 years, 60.5% women, 65.7% Hispanic). The participants were followed for an average of 10.4 years (IQR 9.5-12.6). The prevalence of high-degree intracranial stenosis was 3.5% (74% isolated anterior circulation, 21% isolated posterior circulation, and 5% anterior and posterior circulation). In univariate analysis, high-degree intracranial stenosis was associated with older age (P=0.003), hypertension (P=0.02) and diabetes (0.02). The risk of vascular death and stroke was higher among stroke-free individuals with high-degree intracranial stenosis (table), and in particular with strokes due to large artery atherosclerosis.

Conclusions:
Evidence of high-degree intracranial stenosis among stroke-free individuals identifies those at risk of vascular events and may be used to select individuals for testing aggressive measures to reduce vascular risks.
Abstract 183: Prognosis of Intracranial Arterial Dolichoectasia in Patients With Ischemic Cerebrovascular Disease
Authors: Zhang Xinmiao , Jing Jing , Zhao Xingquan , Liu Liping , Meng Xia , Pan Yuesong , Wang Yilong , Wang Yongjun
Published: January 2019

Objectives:
Intracranial arterial dolichoectasia (IADE) refers to the vascular abnormities of elongation, tortuous, and dilating of the brain vessels. The incidence of IADE in patients with ischemic cerebrovascular disease was higher, however, the prognosis of IADE in patients with ischemic cerebrovascular diseases was still not clear. The purpose of this study was to explore the association between the IADE and the clinical prognosis of patients with ischemic cerebrovascular disease in China.

Methods:
Patients with acute ischemic stroke and transient ischemic attack were enrolled in a prospective, multicenter cohort study. Baseline clinical information and follow-up information were collected. The imaging information of the patients (baseline magnetic resonance imaging) was collected, and IADE patients were selected through the centralized double-blinded interpretation. The endpoints included stroke recurrence, composite events, and all-cause mortality at 12 months. The multivariate Cox regression model was used to explore the association between IADE and the clinical prognosis of ischemic cerebrovascular disease.

Results:
8219 patients with ischemic cerebrovascular disease were enrolled in this study, 395 patients of whom had IADE. Patients with IADE had a lower stroke recurrence rate (4.8% vs 7.8%, P=0.03) and lower composite events rate (5.3% vs 8.1%, P=0.04) at 12 months. The elongation of the basilar artery was also associated with stroke recurrence (6.8% vs 8.4%, P=0.009) and composite events rate (7.1% vs. 8.7%, P=0.009) at 12 months. After multivariate Cox regression, IADE was still independently associated with decreased stroke recurrence (HR 0.59, 95% CI 0.36-0.95,P=0.03) and composite events (HR 0.63, 95% CI 0.40-0.99,P=0.05) at 12 months . The elongation of the basilar artery was still independently associated with decreased stroke recurrence (HR 0.80, 95% CI 0.67-0.95, P=0.01) and composite events (HR 0.81, 95% CI 0.68-0.95, P=0.01) at 12 months.

Conclusion:
IADE and the elongation of the basilar artery were both independently associated with decreased stroke recurrence and composite events at 12 months.