bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract 91: Moyamoya Disease Susceptibility Gene,
RNF213
p.R4810K Variant, is a Common Risk Factor for Atherothrombotic Brain Infarction in a Japanese Population
Authors: Okazaki Shuhei , Morimoto Takaaki , Kamimura Teppei , Kobayashi Hatasu , Harada Kouji , Tomita Tsutomu , Higashiyama Aya , Takahashi Jun C , Nakagawara Jyoji , Toyoda Kazunori , Koizumi Akio , Ihara Masafuji
Published: October 2018

Background and Purpose:
RNF213
has been identified as a susceptibility gene for moyamoya disease. The p.R4810K variant is found in about 80% of East Asian patients with moyamoya disease, and 20 - 25% of those with proximal intracranial arterial stenosis. In this study, we examined the association of
RNF213
p.R4810K variant with non-cardioembolic stroke in a Japanese population.

Methods:
We analyzed 383 consecutive patients with acute non-cardioembolic stroke, who were admitted to the National Cerebral and Cardiovascular Center from June 2012 to May 2017 and participated in NCVC Biobank, and 1011 healthy local Japanese controls. Patients diagnosed with moyamoya disease were excluded. Written informed consent was obtained from all study participants. Odds ratios (OR) and 95% confidence intervals (CI) were adjusted for age, sex, and conventional risk factors for stroke.

Results:
The
RNF213
p.R4810K variant was found in 5.2% of acute non-cardioembolic stroke patients and in 2.1% of healthy controls (adjusted OR 3.9, 95% CI 1.6 - 9.3, p=0.003). The mean age of stroke onset was lower in patients with the
RNF213
p.R4810K variant than those without the variant (58.1±15.5 years vs. 69.1±13.2 years, p<0.001). Among stroke subtypes, only atherothrombotic brain infarction (ATBI) was significantly associated with this variant (adjusted OR 11.5, 95% CI 3.4 - 36.2, p<0.001, see also Table 1). When stratified by sex, these associations were more evident in women (Men: adjusted OR for ATBI 1.9, 95% CI 0.3 - 10.2, p=0.47; Women: adjusted OR for ATBI 58.0, 95% CI 10.3 - 327.3, p<0.001, see also Table 1).

Conclusion:
The
RNF213
p.R4810K variant is a genetic risk factor for non-cardioembolic stroke in Japan, especially for atherothrombotic brain infarction in women.
Abstract 93: Using Discrete Event Simulation to Assess the Regionally-Specific Impact of the Severity-Based Stroke Triage Algorithm for EMS on Patient Outcomes and Overtriage
Authors: Bogle Brittany M , Rosamond Wayne D , Asimos Andrew
Published: October 2018

Introduction:
We previously developed a discrete event simulation environment to evaluate the regional impact of the AHA/ASA’s Severity-Based Stroke Triage Algorithm for EMS. It now is capable of projecting patient outcomes.

Methods:
We simulated EMS-assessed suspected acute ischemic stroke (AIS) patients with last known well < 6 hours over a year in Mecklenburg County, NC. Patients were geographically distributed per projected census tract estimates. Suspected large vessel occlusion (LVO) AIS patients were routed to an endovascular stroke center (ESC) under varied screening tools and transport time rules. LVO patients initially transported to non-ESCs were transferred to an ESC after IV-tPA. Based on patient type (LVO, non-LVO AIS, non-AIS) and hospital type (ESC, non-ESC), we probabilistically assigned time to hospital arrival, imaging, IV-tPA, transfer, and endovascular thrombectomy. Patient survival and modified Rankin Score (mRS) were estimated as a function of time and type of treatment received. Overtriage was calculated as the percent of patients unnecessarily transported directly to ESCs due to false positive screens.

Results:
An average of 2172 patients (172 LVO, 556 non-LVO AIS, 1444 non-AIS) were screened annually. Results by stroke severity screen and transport time rule are in the Table. For example, using C-STAT and a 10 minute transport threshold: 559 (79%) of direct arrivals to ESCs were overtriaged; 58% of LVOs were directly transported to an ESC; and 54% of LVOs received endovascular thrombectomy within 6 hours. Of LVOs, 82% survived, 37% achieved an mRS ≤2. Of non-LVO AIS patients, 91% survived and 50% achieved mRS≤2.

Conclusions:
Our data suggest the burden of overtriage with some algorithm implementations may outweigh the marginal gains in survivors and patients with favorable neurological discharge, but this likely varies by region, demonstrating the value of leveraging such modeling environments for tailoring triage algorithms.
Abstract 96: Assessment of the Rapid Arterial oCclusion Evaluation (RACE) Scale in Real-World Practice for Prediction of Large Vessel Occlusion and Reducing Time to Thrombectomy
Authors: Mehta Brijesh P , Jadhav Ashutosh , Sessa Joy , Katz Randy , Duong Hoang , Lima Andrey , DiMartini Gina , Woodall Lakota , Antevy Peter , McTaggart Ryan , Chandra Ronil V , Leslie-Mazwi Thabele M , Hirsch Joshua A , Yoo Albert J , Jovin Tudor , Nogueira Raul G
Published: October 2018

Background:
Pre-hospital identification of potential large vessel occlusion (LVO) stroke patients may lead to faster triage and treatment. We examined whether the RACE scale can be reliably implemented in a real-world setting with multiple EMS agencies and lead to rapid treatment.

Methods:
A prospective study was performed at a high volume comprehensive stroke center. In the first phase, eight EMS agencies were educated on use of the RACE scale using an online training video. All EMS stroke alerts were recorded. When EMS RACE score was 5 or higher, the neurocath lab team was alerted prior to EMS arrival as part of a parallel workflow. Upon ER arrival, the following characteristics were tracked: NIHSS score, RACE score, CT findings, presence of LVO and workflow time metrics.

Results:
During the study period (January 2016 to June 2017), RACE score was provided for 797 of 1498 EMS stroke alerts (53%). Higher pre-hospital RACE scores correlated with NIHSS scores. LVO was found in 106 (13%) of patients with an available RACE score. A RACE score of 5 or higher was able to identify 64% of all LVO patients (sensitivity: 64%; specificity: 72%; PPV: 30%; NPV: 93%; accuracy: 71%; Youden’s index). However, of the 260 patients with RACE score 5 or higher, only 68 patients (26%) were found to have LVO while 29 patients (11%) had ICH (figure); among 499 patients with RACE score less than 5, LVO was present in 38 patients (8%). When an EMS stroke alert with high RACE score triggered early alert of the neurocath lab team, median door to groin puncture time for thrombectomy was 65 minutes compared to 91 minutes for cases with sequential workflow.

Conclusion:
The RACE scale can be successfully implemented across EMS agencies and results in faster door to groin puncture times. While a RACE score of 5 or higher is associated with greater likelihood of LVO, there are a significant number of false positives. Further refinement of pre-hospital stroke severity scales is warranted to improve the accuracy of this approach.
Abstract 97: Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Persons With Suspected Stroke: A Systematic Review for the 2018 AHA/ASA Guidelines for the Early Management of Patients With Acute Ischemic Stroke
Authors: Smith Eric E , Kent David M , Bulsara Ketan R , Leung Lester Y , Lichtman Judith H , Reeves Mathew J , Towfighi Amytis , Whiteley Willian N , Zahuranec Darin B
Published: October 2018

Introduction:
Prediction instruments for large vessel occlusion (LVO) have been proposed to identify patients for rapid transport to endovascular thrombectomy (EVT) capable hospitals. This Evidence Review Committee was commissioned by the AHA/ASA to systematically review evidence for the accuracy of LVO prediction instruments.

Methods:
Medline, Embase, and Cochrane databases were searched on October 27, 2016. Study quality was assessed using the Quality Assessment of Diagnostic Accuracy (QUADAS)-2 tool.

Results:
Thirty-six relevant studies were identified. Most (21/36) recruited patients with confirmed ischemic stroke, with few studies in the pre-hospital setting (4/36) and in populations that included hemorrhagic stroke or stroke mimics (12/36). Most studies had either some risk of bias or unclear risk of bias. Discrimination of LVO, as measured by the c-statistic, mostly ranged from 0.70-0.85. In meta-analysis, no threshold on any instrument predicted LVO with both high sensitivity and specificity (Table). With a positive LVO prediction test, the probability of LVO could be 50% or greater (depending on the LVO prevalence in the population), but the probability of LVO with a negative test could still be 10% or more.

Conclusions:
No scale predicted LVO with both high sensitivity and specificity. Systems that use LVO prediction instruments for triage will miss some patients with LVO and milder stroke. More prospective studies are needed in the pre-hospital setting in all patients with suspected stroke, including hemorrhagic stroke and stroke mimics.
Abstract NS2: A Rapid Care Evaluation Transient Ischemic Attack Clinic by Nurse Practitioners
Authors: Dvoren-Baker Tina M , Holmstedt Christine A , Hegedus Mary A , Kerrigone Jennifer T , Matuskowitz Andrew J , Jauch Edward C , Ovbiagele Bruce I , Turan Tanya N
Published: October 2018

Background:
Prompt evaluation and management of patients having a transient ischemic attack (TIA) with the ABCD2 triage score has been shown to decrease the risk of stroke and potentially life-long disability. However, creating an organized, well-coordinated approach that provides rapid access for patients is a challenge at many high-volume stroke centers.

Purpose:
We sought to determine the feasibility of a nurse practitioner (NP)-led Rapid Access Care Execution for Transient Ischemic Attack (RACE-TIA) Clinic as part of an Outpatient Stroke Nurse Practitioner Clinic.

Methods:
Our RACE-TIA Clinic Algorithm uses ABCD2 score triaging, and outlines the care process for TIA patients who present either through the Emergency Department (ED), Outpatient Clinic or via telephone triage. Patients with possible TIA are triaged using the ABCD2 tool. Those who present to the ED are evaluated by a member of the Acute Stroke Team and patients with a score ≥ 3 remain in the ED Clinical Decision Unit (CDU) for evaluation. Patients with a score < 3 are scheduled in the RACE-TIA Clinic staffed by two stroke-trained NPs. Referrals to the RACE-TIA clinic from the electronic medical record (EMR) referral or the dedicated phone line are triaged by a registered nurse who was trained to complete the ABCD2 scoring. All appointments are scheduled within 24-48 hours of receiving a referral.

Results:
Since initiating the RACE-TIA Clinic Algorithm in January 2017 a total of 20 patients were seen as outpatients for TIA evaluation. Six patients were directly referred to the RACE-TIA Clinic for acute TIA evaluation and of those, 5 were referred from the ED and 1 from a primary care office. Another 14 patients were scheduled for follow-up after having an initial TIA evaluation at either an outside hospital (3), the ED (2), ED CDU (3) or after inpatient hospitalization (6). The average time from referral to clinic visit was 34 hours.

Conclusion:
Our NP-led RACE-TIA Clinic has successfully evaluated patients with low risk TIA in the outpatient setting in a timely way and also provided close follow-up for high risk TIA patients after the acute evaluation without expanding or duplicating existing resources.
Abstract NS7: Driving Down Readmissions With Dynamic Discharge Follow up Team
Authors: Richardson Alicia , Morrison Kathy , Light Ritu , Miller Annette
Published: October 2018

Introduction:
Stroke patients have complex discharge needs and benefit from strong care transition models. A common care transition model is to perform discharge phone calls to eliminate gaps that may have occurred after discharge. Institutions often struggle with performing discharge phone calls - who should perform this task and what the optimal timeframe should be. Ninety percent of this institution’s 30-day readmissions occur within the first 7 days of hospital discharge, with majority due to medication misunderstanding and poor communication. Hospital readmissions have negative consequences for patients and are costly, accounting for $15 billion of Medicare dollars annually.

Methods:
In 2014, stroke discharges to home received a 48 hour phone call from an outpatient Registered Nurse (RN) Care Manager. In 2015, to address the medication challenges, a Pharmacist was added to the discharge follow-up team, making phone calls within 7 days of discharge.

Results:
In 2016, 233(61%) of the 48-hour calls by RNs connected successfully with stroke patients discharged to home. Pharmacist calls reached a higher percentage of patients discharged to home at 83% (n=321). There were 53% (n=208) receiving both calls, and 25% (n=97) of patients being unable to reach after three attempts. The resultant 30-day readmission rate has declined from 8-10% in 2013 and 2014 (when we first started tracking 30-day readmission rates) to 2-3% in 2015. This low rate has remained consistent for 2016 and 2017.

Conclusion:
Although post-discharge calls can be very labor intensive and time consuming, it is possible to clarify communication, ensure understanding of discharge instructions, and intervene before medication errors occur. The unique combination of an RN and Pharmacist performing the discharge phone calls has been shown to be quite effective; the RN triages acute issues, while the Pharmacist ensures accurate medication list and compliance - and ensures no medication changes were inadvertently made at a primary care provider appointment post-discharge. These interventions reduce readmissions by closing the post-discharge gaps in care that can occur, resulting in a win for both the patient and the institution.
Abstract NS9: The Use of Motivational Interviewing in Maintaining Optimal Blood Pressure Post Stroke
Authors: Nwosu Uzoamaka N
Published: October 2018

Background:
Stroke is one of the most preventable causes of chronic illness, yet it ranks as the first leading cause of disability and the fifth leading cause of death worldwide. Stroke patients are at high risk of having recurrent strokes. Strokes are associated with many risk factors, and hypertension is the most consequential modifiable risk factor for the primary prevention of both ischemic and hemorrhagic strokes. The goal for providers is to utilize evidence-based approaches in helping these patients reduce the risk for stroke re-occurrence.

Method:
A 6- week project was carried out to examine the effectiveness of motivational interviewing (MI) in helping stroke patients with high blood pressure reduce their blood pressure less than 140/90 mm Hg and improve their motivation to maintaining a healthy lifestyle. Twenty stroke patients admitted at the study hospital with past medical history of high blood pressure were recruited in the study and 15 completed the project. After discharge, 20- minute phone calls were made using the MI technique to assess and address their barriers to maintaining optimal blood pressure. Hypertension Self-Care Profile (HBP SCP) questionnaires were given to each of the patients in the hospital and at week 6 during follow-up visit to assess motivation to self-care practices for HBP. At 6 weeks their final blood pressures were obtained at the clinic.

Results:
A one-sided t-test showed that 60%, N=9 participants systolic blood pressure was less than 140 Hgmm with an ending systolic mean of 133.4 hgmm (p=0.055) and with the diastolic blood pressure, 73% of participants N=11 had a diastolic blood pressure less than 90 Hgmm (p= 0.0049), with the ending diastolic mean of 83.07 hgmm. Sixty percent, N =9 participant’s MI scores improved when comparing the pre and post scores (p=0.005).

Conclusions:
The findings suggest that MI could be effective in decreasing patients’ blood pressure less than 140/90 mm Hg and in improving their motivation to maintaining a healthy lifestyle. Based on the findings, it was recommended that motivational interviewing be adopted by advanced practice providers and the nurses in the neurology department to make consistent follow-up phone call to all the stroke patients discharged from the hospital.
Abstract TMP103: Neuroplasticity of Functional Connectivity in Language Networks in Children After Perinatal Stroke
Authors: Carlson Helen L , Sugden Cole , Kirton Adam , Brooks Brian L
Published: October 2018

Background:
Acquisition of language during development is imperative for lifelong functioning. Perinatal stroke is an ideal human model of developmental neuroplasticity. Many children with perinatal stroke (arterial ischemic stroke [AIS] or periventricular venous infarction [PVI]) have intact language function despite damage to language areas. We examined the strength of functional connectivity of language networks in children with perinatal stroke.

Methods:
Participants were recruited from a population-based perinatal stroke cohort and compared to right-handed typically developing controls (TDC). All were scanned at rest using a 3T GE MRI (36 slices, 3.6mm isotropic, repetition/echo time=2000/30ms, 150 volumes, ~6:00). Language networks were identified using a seed based technique measuring blood oxygen level dependent responses in bilateral inferior frontal gyrus (IFG) and posterior superior temporal gyrus (pSTG). Seed-to-seed temporal correlations quantified connectivity. Standardized language outcomes for a subset included measures of vocabulary (WISC-IV Vocabulary) and fluency (NEPSY-II Word Generation Initial Letter).

Results:
The population was 68 children aged 6-19 (17 AIS [mean age 14.0±4.1], 15 PVI [12.8±4.0], 36 TDC [12.9±3.6]). Seven of 13 stroke children (54%) scored below the 10
th
percentile on the word generation task. TDC showed stronger interhemispheric connectivity between frontal (LIFG-RIFG r=0.82±0.3) and temporal (LpSTG-RpSTG r=0.79±0.2) areas compared to intrahemispheric (LIFG-LpSTG r=0.46±0.2; RIFG-RpSTG r=0.39±0.3). For AIS, interhemispheric connectivity between left and right IFG was lower than TDC regardless of stroke side [p<0.001]. For AIS with a left lesion, intrahemispheric connectivity in the right hemisphere appeared higher than TDC [p=0.051]. Connectivity for PVI participants was comparable to TDC. Neither intra- nor interhemispheric connectivity appeared to relate to language function in this simple network.

Conclusions:
Functional strength of language networks is altered after AIS but not PVI. Connectivity of larger language networks needs further investigation to explore compensatory mechanisms and may help target language rehabilitation.
Abstract TMP112: Left Atrial Enlargement is Associated With Anticoagulation Failure in Patients With Acute Ischemic Stroke and Atrial Fibrillation
Authors: Dakay Katarina , Chang Andrew D , Hemendinger Morgan , Cutting Shawna M , McTaggart Ryan A , Jayaraman Mahesh V , Chu Antony , Panda Nikhil , Song Christopher , Merkler Alexander , Gialdini Gino , Kummer Benjamin , Lerario Michael P , Kamel Hooman , Elkind Mitchell S , Furie Karen L , Yaghi Shadi
Published: October 2018

Background:
Biomarkers to predict anticoagulation failure in patients with atrial fibrillation (AF) may help identify high-risk AF patients for further study. We hypothesize that left atrial enlargement (LAE) is more prevalent in AF patients admitted with ischemic stroke who are therapeutic, as opposed to non-therapeutic (NT), on anticoagulation.

Methods:
We included consecutive patients with AF admitted with a diagnosis of ischemic stroke between April 1
st
, 2015 and December 31
st
, 2016. Patients were divided into two groups based on whether they were therapeutic (warfarin with international normalized ratio ≥ 2.0 or non-vitamin K oral anticoagulant with uninterrupted use in the prior 2 weeks) vs. non-therapeutic on anticoagulation. We compared clinical and imaging characteristics, cardiac data (left atrial diameter on transthoracic echocardiogram), and outcomes (discharge modified Rankin Scale, discharge disposition, and symptomatic intracranial hemorrhage [sICH]) between the two groups. Multivariable logistic regression was used to estimate associations between therapeutic anticoagulation and variables, including CHADS
2
score and LAE (none/mild vs. moderate/severe).

Results:
We identified 225 patients; 52 (23.1%) were therapeutic on anticoagulation. The baseline demographics and risk factors were similar between the two groups. Patients therapeutic on anticoagulation were more likely to have a larger left atrial diameter (45.6 ± 9.2 vs. 42.3 ± 8.6 mm, p = 0.032), a higher CHADS2 score (2.9 ± 1.1 vs. 2.4 ± 1.1, p = 0.03), and sICH (13.5% vs. 3.5%, p = 0.013). After adjusting for the CHADS
2
score, patients who had stroke despite therapeutic anticoagulation were more likely to have moderate to severe LAE (odds ratio 2.05, 95% confidence interval 1.01-4.16). Results were unchanged when the CHA
2
DS
2
-VASc score was used.

Conclusion:
LAE is associated with anticoagulation failure in AF patients admitted with an ischemic stroke. This provides indirect evidence that LAE may portend failure of anticoagulation therapy in patients with AF; further studies are needed to delineate the significance of this association and improve stroke prevention strategies.
Abstract TMP113: Do Preceding Direct Oral Anticoagulants Make Stroke Milder in Patients With Atrial Fibrillation? -K-PLUS Registry
Authors: Nakajima Makoto , Ito Yasuteru , Takita Tomohiro , Wada Kuniyasu , Inatomi Yuichiro , Yonehara Toshiro , Terasaki Tadashi , Hashimoto Yoichiro , Ando Yukio
Published: October 2018

Background:
Stroke severity is mitigated by preceding anticoagulants in acute stroke patients with atrial fibrillation (AF). Such mitigative effects might be different between warfarin and direct oral anticoagulants (DOACs). We compared stroke severity and characteristics in patients who had specific antithrombotics to patients without any prophylactics.

Methods:
We recruited data from K-PLUS Registry, a regional multicenter stroke registry, between 2009 and 2017. Patients who had AF diagnosed before onset or during hospitalization were included. Background characteristics, stroke severity, and in-hospital death were analyzed according to preceding antithrombotic agents (warfarin, DOACs, antiplatelets aone, or none) at onset.

Results:
Out of 6,697 participants, 1,765 (median 82 years old) had AF; 526 (30%) were prescribed warfarin, 196 (11%) DOACs, 365 (21%) antiplatelets alone, and 526 (38%) were none. Proportion of patients with CHA
2
DS
2
-Vasc score ≥2 was the lowest in patients without anticoagulants (91.7%). Patients taking DOACs were younger (median 79 years), and more frequently resided home. Large lesions were more prevalent in patients with antiplatelets (28%) or those with no antithrombotics (28%) compared to those with DOACs (12%) or with warfarin (21%). NIHSS score was the lowest in patients with DOACs (median 5) compared to those with warfarin (10), antiplatelets (11), or none (13), and in-hospital mortality was also the lowest (4.6%, 6.0%, 9.4%, and 8.0%, respectively). When non-antithrombotics patients were used as a reference, adjusted odds ratio for moderate to severe stroke (NIHSS score ≥16) was 0.53 (95% confidence interval, 0.36-0.77) in those with DOACs, while 0.92 (0.72-1.17) in those with warfarin and 0.94 (0.71-1.23) in those with antiplatelets.

Conclusion:
In this regional multicenter cohort, preceding DOACs prescription might mitigate stroke severity in AF patients more strongly than other antithrombotics.
Abstract TMP115: Identifying Overlooked Risk Factors For Stroke From A Prediction Model Constructed From Half A Million Adults In Taiwan
Authors: Wen Chi Pang , Hsu Chung Y , Lee June Han , Lu Po Jung , Tsai Min Kuang
Published: October 2018

Background:
American Stroke Association has listed hypertension, smoking, diabetes, high cholesterol, physical inactivity and atrial fibrillation as the major risk factors for stroke. We developed a new model to predict stroke mortality using the 15-year prospective data of half a million adults in Taiwan. The model identified additional important risk factors.

Method:
In a health surveillance program conducted from 1994 to 2008, a cohort of 541,047 adults were recruited. Among them, we identified 18,296 deaths, including 946 deaths from Ischemic stroke and 597 deaths from hemorrhagic stroke. We developed a prediction model for stroke mortality, with the area under ROC curve of 0.921 for all stroke, of 0.949 for ischemic stroke or of 0.936 for hemorrhagic stroke. As many as 14 variables or confounders were controlled by Cox model in calculating hazard ratios (HR).

Results:
In addition to hypertension, smoking, diabetes, inactivity and high cholesterol, this prediction model revealed that chronic kidney disease (CKD), either proteinuria or low GFR, low total cholesterol (<160 mg/dL) or HDL cholesterol (<35 mg/dL), rapid heart rate (≧90 beats/min), elevated C-Reactive Protein (CRP) (>3 mg/dL), Aspartate Aminotransferase (AST) (≧40 IU/L), and uric acid (≧7 mg/dL) were also important risk factors associated with stroke deaths. In contrast, physical activity reduced mortality from total stroke by 29%, from ischemic stroke by 32% and from hemorrhagic stroke by 22%.

Conclusion:
In addition to commonly known risk factors, we identified from this Chinese population at least 6 additional risk factors for stroke: (1) CKD, either proteinuria or low GFR, (2) low total or HDL cholesterol, (3) rapid heart rate, (4) elevated CRP, (5) elevated AST and (6) elevated uric acid. Being physically active is a powerful modifier, which could reduce stroke mortality by one third. Primary prevention of stroke should extend our consideration to controlling these additional risk factors and encourage regular exercise.
Abstract TMP116: Predictors of Readmissions Following Percutaneous Patent Foramen Ovale Closure in a Nationally Representative Dataset
Authors: Stein Laura K , Kaur Gurmeen , Liang John , Tuhrim Stanley , Tuhrim Stanley , Dhamoon Mandip S
Published: October 2018

Introduction:
The optimal management of patients with recurrent stroke and patent foramen ovale (PFO) is debated. While some are managed medically with antiplatelet/anticoagulant agents, others undergo percutaneous closure of PFO (PC PFO). Device-specific trials have demonstrated a risk of atrial fibrillation/flutter (AF) following closure. To date, nationally representative data has not yet been used to assess the rates and causes of readmission following PC PFO.

Methods:
The 2013 Nationwide Readmissions Database is a national database of readmissions for all payers and the uninsured with data on >14 million U.S. admissions. We used validated International Classification of Disease, Ninth Revision, Clinical Modification codes to identify PC PFO, ischemic stroke, and medical comorbidities and complications. We calculated readmission rate following PC PFO. We performed Kaplan-Meier analysis to determine the cumulative 1-year risk of readmission with AF and Cox regression modelling to calculate hazard ratios (HR) of AF readmission at 1 year.

Results:
Among 850 patients who underwent PC PFO, there were 151(17.7%) readmissions within 1 year and 52 within the first 30 days. 11.5% of 30-day readmissions were for atrial fibrillation and 3.9% for flutter. Kaplan-Meier cumulative risk for readmission with AF at 1 year was 2.17%. Readmission rate for ischemic stroke was <1% (0.38%, 0.69%, and 0.61% at 30, 60, and 90 days respectively), compared to just over 1% for AF (1.15%, 1.38%, and 1.37% at 30, 60, and 90 days respectively). Predictors of AF readmission included history of congestive heart failure (CHF) (HR 3.53, 95% CI 1.23-10.17, p = 0.02) and increasing age (HR 1.05 per year, 1.02-1.09, p = 0.002).

Conclusion:
1 in 5 of those who undergo PC PFO are readmitted in the first year, and 1/3 of these readmissions occur within 30 days. PC PFO is associated with low readmission rates for stroke and a low risk of the independent vascular risk factor of AF. The hazard for AF is over 3-fold greater for those with CHF and increases with each year increase in age.
Abstract TMP118: Outcomes of Previously Identified Transient Ischemic Attack Among Acute Ischemic Stroke Hospitalization and Predictors of Fatal Stroke
Authors: Lavado Liseth , Yousuf Salma , Rasul Bakhtiar , Patel Shyam , Mahvish Gull , Habib Anam , Patel Janki , Bhesania Siddharth , Mehta Parag , Patel Urvish K
Published: October 2018

Background:
Patients with transient ischemic attack (TIA) or minor stroke are at increased risk of recurrent stroke, and therefore require urgent evaluation and treatment since immediate intervention may substantially reduce the risk of recurrent stroke and improve the outcome. We hypothesized that AIS hospitalizations with previously identified/personal medical history (PMH) of TIA are associate with lower all cause in-patient mortality, likelihood of death and disability.

Methods:
We performed a population-based retrospective analysis of the Nationwide Inpatient Sample (NIS) (years 2007-2013) in adult hospitalizations for AIS to compare the outcomes [Death, APRDRG Risk Mortality (likelihood of dying), and APRDRG Severity (loss of function)] amongst TIA patients using ICD-9-CM codes. We performed weighted analyses using Chi-square and Jonckheere-Terpstra trend test. Multivariate survey logistic regression was done to evaluate the association of PHO TIA with poor outcomes and predictors of fatal stroke in PHO TIA patients.

Results:
Between years 2007 to 2013, total 3,082,973 patients with stroke were hospitalized. Of these admissions, 315,026(10.22%) patients also had PMH of TIA as a concurrent diagnosis. There was a substantial increase in rates of PMH TIA among stroke patients; 1.28% in 2007 to 13.34% in 2013 (p<0.0001). On multivariate regression analysis, there was a statistically significant lower mortality (OR:0.8; 95%CI:0.75-0.85), Risk Mortality (OR:0.85; 95%CI:0.82-0.88), and Risk Severity (OR:0.87; 95%CI:0.84-0.89) in stroke patients with PMH TIA compared to those without PMH TIA or unidentified TIA. Independent predictors of fatal stroke in PMH of TIA patients included age >80 (aOR:3.98; 95%CI:1.15-13.76), comorbid congestive heart failure (aOR:1.79; 95%CI:1.53-2.09), coagulopathies (aOR:1.47; 95%CI:1.06-2.04), hemorrhage transformation (aOR:4.65; 95%CI:3.49-6.19), and atrial fibrillation (aOR:1.77; 95%CI:1.54-2.03).

Conclusion:
We observed better outcomes amongst pre-identified TIA patients during stroke hospitalization than previously non-reported. That’s why risk stratification and secondary prevention play a very crucial role to improve outcomes of stroke by identifying and managing TIA.
Abstract TMP14: Thrombolysis in Ischemic Stroke Patients with Prior History of Intracranial Hemorrhage
Authors: Chu Stacy Y , Sommaruga Samuel , Hwang David , Dearborn Jennifer , Sansing Lauren , Matouk Charles , Samarth Gargi , Petersen Nils , Gilmore Emily , Schindler Joseph , Sheth Kevin N , Falcone Guido J
Published: October 2018

Introduction:
The recently updated FDA label for intravenous recombinant tissue plasminogen activator (IV-tPA) for stroke removed a history of intracranial hemorrhage (ICH) as a contraindication. The safety of IV-tPA in patients with prior ICH is not well-established, as only a few cases are described in the literature. We sought to determine (1) the proportion of patients treated with IV-tPA for stroke who have prior history of ICH and (2) whether this circumstance influences in-hospital mortality.

Methods:
Using administrative claims data on admissions to California hospitals between 2005-2011, we performed a cross-sectional study of adult patients admitted with acute ischemic stroke who received IV-tPA. ICD-9-CM codes were used to identify these patients and to ascertain prior diagnoses of (1) ICH, including intracerebral hemorrhage (IPH), subarachnoid hemorrhage (SAH), subdural hematoma (SDH), or epidural hematoma (EDH); and (2) existing comorbidities. We used multivariable logistic regression to model the odds of in-hospital mortality as a function of prior ICH, after adjusting for potential confounders.

Results:
Among 372,167 patients admitted with acute ischemic stroke during the study period, 10,882 (2.9%) received IV-tPA (mean age 70.6 [SD 14.6], female 5,614 [54.8%]). Among these, 268 (2.5%) patients had a diagnosis of prior ICH on admission, including IPH 194 (1.8%), SAH 81 (0.7%), SDH 9 (0.1%) and EDH 2 (0.0%). In-hospital mortality was 12.2% overall, 11.7% for patients without prior ICH, and 31.0% for patients with prior ICH (p<0.001). In adjusted analyses, prior ICH remained independently associated with in-hospital mortality (OR 3.48, 95% CI 2.63-4.56, p<0.001), as did most ICH subtypes, including IPH (OR 2.97, CI 2.12-4.09, P<0.001), SAH (OR 3.15, CI 1.89-5.12, P<0.001), and SDH (OR 4.27, CI 0.87-16.95, P=0.047).

Conclusions:
In California between 2005-2011, 2.5% of acute ischemic stroke patients who received thrombolysis had a prior diagnosis of ICH. In this population, a history of ICH was associated with mortality; this association held true for ICH subtypes IPH, SAH and SDH. Further observational and experimental studies are needed to confirm the observed associations.
Abstract TMP15: Penumbral Rescue by Normobaric O2 in Ischemic Stroke With Target Mismatch ProFile (PROOF)
Authors: Poli Sven , Baron Jean-Claude , Lemmens Robin , Michel Patrik , Mikulik Robert , Molina Carlos , Strbian Daniel , Tatlisumak Turgut , Turc Guillaume , Fiehler Jens , Graessner Holm , Hüsing Johannes , Montaner Joan , Siemonsen Susanne , Berge Eivind , Randall Gary , Rosenberger Peter , Audebert Heinrich J , Dichgans Martin , Singhal Aneesh , Veltkamp Roland , Härtig Florian
Published: October 2018

Introduction/Hypothesis:
Despite effective reperfusion therapies, outcome following ischemic stroke (IS) often remains poor. Shortly after IS onset, the already necrotic area is surrounded by the severely hypoperfused but still viable penumbra. Sustaining the latter may widen treatment time windows and improve outcomes. As tissue damage in IS is primarily mediated by hypoxia, increasing penumbral oxygen (O2) supply seems a logical approach. Normobaric hyperoxygenation (NBHO) increased penumbral O2 and attenuated brain injury when initiated early in animal models of transient vessel occlusion. The few clinical trials conducted so far did not adapt these insights: NBHO initiation was late (treatment windows of more than 9 hours) and patients eligible for intravenous thrombolysis and endovascular treatment were excluded.

Methods:
Multi-center, randomized phase-II proof-of-concept trial studying NBHO adjunct to standard IS treatment; adaptive patient sample size of 180 to 460 depending on interim analysis.

Eligibility:
Patients with an acute large vessel occlusion in the anterior circulation (terminal ICA plus M1, proximal M1, or distal M1) and an Alberta Stroke Program Early CT Score of 7 or higher. Study treatment must be initiated prior to recanalization therapy and within 3 hours after IS onset. NBHO is achieved by administration of high-flow O2 (40 L/min) via non-rebreather face mask with reservoir or FiO2 of 1.0 during mechanical ventilation. NBHO will be stopped after endovascular treatment or applied for a maximum of four hours in case of not-attempted endovascular treatment. Controls will receive standard O2 supplementation whenever required.

Primary Endpoint:
Infarct growth from baseline to 24 hours; key secondary endpoint: Δ24h-NIHSS.

Conclusion:
PROOF is the first clinical trial to incorporate two cornerstones of effective experimental NBHO: early initiation and fast reperfusion. If proven beneficial, phase-III trials may be undertaken. Considering its low cost, NBHO may impact stroke care worldwide.
Abstract TMP19: Long Term Functional Outcome of Intravenous Alteplase Administered Over Telestroke
Authors: Al Kasab Sami , Harvey Jillian , Reardon Christopher , Anadani Mohammad , Debenham Ellen , Turner Nancy , Aysse Patricia , Holmstedt Christine A
Published: October 2018

Background:
Intravenous alteplase (rtPA) is a proven treatment for acute ischemic stroke. The implementation of telestroke networks increases access to expert stroke care and rtPA administration. Previous studies showed that faster door to needle time (DTN) leads to a better functional outcome; however DTN has been shown to be longer over telestroke when compared to that at a comprehensive stroke center. The purpose of this study is to compare the long term functional outcome of rtPA when administered at spoke hospitals through telestroke consultations to that at the comprehensive stroke center (hub).

Methods:
Data on baseline characteristics and long-term outcomes for all patients evaluated at the Medical University of South Carolina (MUSC) and MUSC telestroke network between January 2016 and March 2017 were collected. Eligible patients received rtPA at either the spoke or hub location during the study period. Data sources included registry data collected from telestroke consultations at 22 different spokes in South Carolina and electronic medical record data for patients at one hub. Patients who received mechanical thromectomy were excluded from the study. Functional outcome was assessed with 90 day Modified Rankin Scale (mRS). To predict the odds of a low category mRS for spoke patients compared to hub, adjusting for patient stroke severity (NIHSS), door to needle time, age, sex, and race, we estimated a logit model. T-tests and Chi-squared were used to examine the differences in continuous and categorical patient variables.

Results:
Total of 426 were identified (60 hub and 366 spoke patients). There were no significant differences in patient age, sex, admission NIHSS, or door to needle times between the two groups. More patients (55%) were white in the hub group compared to (61.8%) in the spoke group (P=0.02). mRS of 0-2 at 90 days was achieved in 37 (61.7%) of the hub and in 255 (69.7%) in the spoke patients (P=0.216). On logistic regression, there was no difference in the adjusted odds of having a lower mRS between spoke and hub patients (OR 1.75, p=0.104, 95% CI [0.89-3.37]).

Conclusion:
Our study shows no difference in the long-term functional outcome for rtPA when administered at spokes through telestroke compared to that at the hub.
Abstract TMP23: Shades of White: Correlation of Hyperacute DWI Intensity With Last Known Well Time
Authors: Chen Michael M , Attenhofer Kevin , Selvan Pradeep , Lunagariya Abhishek , Hailey Lovella , Mortin Melissa , Rapp Karen , Agrawal Kunal , Huisa-Garate Branko , Modir Royya , Meyer Dawn M , Hemmen Thomas , Meyer Brett C
Published: October 2018

Background:
Identifying a last known well (LKW) time surrogate for acute stroke is vital to increase stroke treatment. Previous research have used an MRI DWI vs. FLAIR mismatch to estimate LKW time to within 6 hours. DWI signal intensity initially increases from onset of stroke, but mapping a reliable time course to the signal intensity has not been demonstrated.

Methods:
We retrospectively reviewed stroke code patients between 1/2016 and 6/2017 from the prospective, IRB approved UCSD Stroke Registry. Patients who had MRI brain from onset, with or without intervention, are included. All ischemic strokes were confirmed with ADC correlation and timing from onset to MRI was calculated. Raw DWI intensity was measured in grays (Gy) using IMPAX software and compared to contralateral side for control, for a relative DWI intensity (rDWI). LKW and MRI time were collected by chart review. Correlation was assessed using Pearson correlation coefficient between DWI intensity, rDWI, and time to MRI imaging. 1.5T, 3T, and combined modalities were examined.

Results:
97 patients were included in this analysis. Overall, there is a good correlation (0.39, p<0.001) for minutes from onset to MRI and DWI intensity. There was good correlation with the 1.5T group (0.39, p=0.001) and very good correlation with the 3T group (0.60, p=0.001). There were no significant differences in demographic or time interval between the two MRI types.

Conclusions:
There is good correlation between DWI intensity and minutes from onset to MRI. This suggests a time-dependent DWI intensity response and supports the potential use of DWI intensity measurements to extrapolate a LKW time in unknown cases. Further studies in a larger dataset within the hyperacute period are being pursued to increase both experience and generalizability.
Abstract TMP29: Type II Diabetes Induces an Early Decline of Neurogenesis With Increased Morphological Alteration in Neuroblasts
Authors: Rabiller Gratianne , Kanoke Atsushi , Daynac Mathieu AP , Petritsch Claudia , Liu Jialing
Published: October 2018

Introduction:
Diabetes increases the severity of stroke outcome and impairs the capacity for neuroplasticity. Evidence suggests that neurogenesis, a mechanism of neuroplasticity, is induced after experimental stroke, although how it is confounded by type 2 diabetes mellitus (T2DM) or aging remains to be clarified.

Hypothesis:
We hypothesize that T2DM exacerbates age-associated reduction in neurogenesis.

Methods:
Experimental stroke was induced by distal middle cerebral artery occlusion (dMCAO) in young (11-13 weeks-old, n=12) and middle-aged (53-75 weeks-old, n=50) db/+ or db/db mice, as well as in db/+ mice of old age (99-124 weeks-old, n=30). Thymidine analog 5-bromo-2′-deoxyuridine-5′(BrdU) was administered i.p. at 50 mg/kg twice daily from days 4-7 after dMCAO to label proliferating cells. Mice were euthanized 28 days after dMCAO and their brain tissue was processed for immunohistochemistry for BrdU and markers of neuronal or glial lineages.

Results:
A significant reduction in the number of DG neuroblasts was found in the db/db compared to db/+ mice in both young and middle-aged groups at baseline and after dMCAO. There was a further decline of neurogenesis in the old db/+ mice compared to the middle-aged db/+ mice by 6.2 and 3 folds at baseline and after dMCAO, respectively. dMCAO induces an increase of DCX(+) neuroblasts in all age groups of db/+ mice but not in db/db mice, suggesting that T2DM elicited an early decline of neurogenesis, leading to a failed regeneration after stroke. Large DCX(+) cells without processes were found in the DG of old db/+ and middle-aged db/db mice. Neuroblasts with aberrant morphology do not express markers of astrocytes or oligodendrocytes, although their identity and nature remains unclear.

Conclusions:
Our data suggest that T2DM accelerates the decline of neurogenesis induced by aging, which may potentially affect the functional outcome of regeneration and post stroke neuroplasticity impacted by this comorbidity. Ongoing investigation will further characterize the functional change of the neuroblasts with altered morphology and determine the effect on differentiation and survival of newborn neurons in the DG of db/db mice.
Abstract TMP35: CD200-CD200R1 Inhibitory Signaling Attenuates Neuroinflammation and Reduces Behavioral Deficits Following Ischemic Stroke
Authors: Ritzel Rodney M , Mamun Abdullah A , Crapser Joshua D , Verma Rajkumar , Patel Anita R , Knight Brittany E , Harris Nia M , Mancini Nickolas S , Liu Fudong , McCullough Louise D
Published: October 2018

Introduction:
In ischemic stroke, central nervous system homeostasis is dysregulated, leading to a significant inflammatory response, cell death, and impaired neuronal survival. The immune-inhibitory CD200-CD200 Receptor 1 signaling axis is a key regulator of inflammation and CNS homeostasis. We investigated the role of CD200R1-mediated signaling in stroke by evaluating the effects of its genetic deletion on inflammation and neurological outcome.

Methods:
Juvenile (10-12 wks) male transgenic CD200R1 knockout and WT littermate control (C57BL/6) mice were subjected to 60-min of reversible right middle cerebral artery occlusion and evaluated at day 3 and 7. Microglia activation and infiltration of peripheral leukocytes were examined by flow cytometry. Behavioral outcome was assessed by open field and rotarod test.

Results:
Early after ischemia (72 hrs), CD200R1 KO mice had no differences in stroke outcome measures compared to wildtype controls. However, significantly more infiltrating monocytes were found in the ischemic brain of CD200R1 KO mice. Monocyte function was uniquely affected by CD200R1-deficiency and resulted in dysregulated polarization. Unlike their WT counterparts, which eventually de-escalated the brain’s inflammatory response to stroke, microglia and monocyte activation persisted out to 7 days in CD200R1 KO mice, and was accompanied by a delayed, but significantly augmented lymphocyte response. At this timepoint, CD200R1 KO mice displayed severe weight loss, greater neurological deficits, impaired motor function, and had poorer survival rates compared to their WT counterparts. Interestingly, we found that microglia did not express appreciable levels of CD200R1 surface protein. Instead, CD200R1 was exclusively expressed on infiltrating monocytes and lymphocytes after stroke.

Conclusion:
Due to its expression on activated peripheral immune cells after stroke, CD200R1 may be a potentially valuable translational target that can inhibit leukocyte transmigration and thus, dampen the overall amplitude of the inflammatory response. This study defines an essential role for CD200-CD200R1 signaling in down-regulating the neuroinflammatory response in the ischemic brain to facilitate post-acute behavioral recovery.
Abstract TMP41: Sensory Function Improvement After 5Hz Contralesional rTMS in Chronic Stroke
Authors: Pundik Svetlana , McCabe Jessica , Skelly Margaret , Tatsuoka Curtis , Akbari Heba , Plow Ela
Published: October 2018

Purpose:
Sensory deficits are prevalent after stroke but effective interventions are limited. Non-invasive brain stimulation is a promising adjunct to peripherally administered rehabilitation therapies. However, the utility of brain stimulation in sensory re-education after stroke has not been tested. The purpose of this study was to assess immediate response to repetitive Transcranial Magnetic Stimulation (rTMS) of the contralesional primary sensory cortex (S1).

Methods:
Stroke survivors (>6 mo post; n=16) with arm sensory deficits participated in 3 different rTMS treatments targeting contralesional S1 as follows: 1) Sham, 2) 5 Hz and 3) 1 Hz. rTMS was paired with peripherally directed modalities (electrical stimulation via mesh glove followed by hand vibration). rTMS paradigms were administered in random order 1 week apart. Outcomes included 2-point discrimination, vibration, monofilament discrimination and proprioception. Measures were collected before and 1 hour after treatment and responses were calculated as post minus pre for each session. Data did not appear to be normally distributed, nor were responses correlated between the 3 treatments. Kruskal-Wallis tests were employed.

Results:
Subjects were 59.8±8.3 years old, 43±38 months after stroke, 88% were male and 59% had subcortical stroke. Baseline sensory impairment for the stroke Affected (A) and Unaffected (U) arms were as follows: 2-point discrimination threshold 12.47±4.73mm (A) and 2.86±1.01mm (U), monofilament 4.98±1.69mm (A) and 3.55±0.55mm (U), proprioception % accuracy at index 71.67±24.6%(A) and 99.37±1.81% (U), vibration amplitude threshold in relative units 9.7±8.6(A) and 4.75±1.8(U). There was an improvement in 2-point discrimination after 5 Hz rTMS in the affected arm; a reduced threshold of 1.68±3.5mm following 5Hz intervention vs reduction of 0.333±1.18mm after 1 Hz and increase of 0.13±2.06mm after sham (p=0.009). The unaffected arm also had improvement in 2-point discrimination of 0.38±0.8mm following 5Hz rTMS compared with increased threshold after both 1Hz (0.6±0.73mm) and sham (0.2±0.77mm) (p=0.009).

Conclusion:
High frequency rTMS targeting contralesional S1 cortex is a potential adjunct intervention for sensory re-education after stroke.