bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP191: DM is Not Related With Poor Outcome in Acute Ischemic Stroke. the GLIAS-II Study
Authors: Gutiérrez-Zuñiga Raquel , Alonso de Leciñana María , Delgado-Mederos Raquel , Gãllego-Culleré Jaime , Rodríguez-Yañez Manuel , Martínez-Zabaleta Maite , Freijo Mar , Portilla-Cuenca Juan C , Gil-Núñez Antonio , Madero-Jarabo Rosario , Lisbona Arturo , Díez-Tejedor Exuperio , Fuentes Blanca ,   Stroke Project Cerebrovascular Diseases Study Group Spanish Society of Neurology
Published: October 2018

Backgrounds:
Diabetes Mellitus (DM) has been widely associated with poor outcome after an ischemic stroke (IS). However the underlying mechanisms are not well elucidated. We aim to study whether the outcome in stroke patients with DM is independent of comorbidity, the development of poststroke hyperglycaemia or due to higher glycaemic variability.

Methods:
Secondary analysis of the GLIAS-II study (multicenter, prospective, observational academic cohort study). We compared outcomes (in-hospital complications; mortality; death or dependence (mRS >2); and stroke recurrence at 3 months) in two study groups: patients with prior diagnosis of DM (DM group) vs. patients without DM (non DM group). We performed multivariate analysis in order to adjust the effect of DM on stroke outcomes by comorbidity (Charlson index), poststroke hyperglycaemia (>155 mg/dL) during the fist 48 h and glycaemic variability (standard deviation and coefficient of variation).

Results:
We included 213 patients, 64 (30%) with DM. The baseline characteristics (age, sex, stroke severity and the proportion of patients treated with intravenous thrombolysis) were similar between groups. There were no differences in in-hospital complications: pneumonia (4.7% vs. 3.4%; P=.699); urine infection (4.7% vs.1.3%;
P
=.161); cerebral edema (6.2% vs. 4%; P=.492); or symptomatic hemorrhagic transformation of the stroke (1.6 vs. 0.7%;
P
=.512) between DM and non DM groups. There was no difference between groups in mortality (12.7 vs. 5.7%; P=.096); death or dependency at 3 months (31.7% vs. 26.4%;
P
=.500), neither in stroke recurrence (3.1 vs. 4%;
P
=1.000) at 3 months. After adjusting for other prognostic factors, DM was not associated with any of the studied outcomes, whilst glycaemic variability was independently associated with mortality (p=0.032) and hyperglycemia within 48 hours with death or dependence (p=0.049).

Conclusion:
DM itself was not associated with poor outcome in acute stroke patients admitted to SU, being glycaemic variability and poststroke hyperglycemia risk factors for mortality and death or dependence respectively.
Abstract WP193: Non-fatal Stroke and All-cause Mortality Among Community-dwelling Older Adults Living in Rural Ecuador. A Population-based, Prospective Cohort Study
Authors: Del Brutto Victor J , Mera Robertino M , Lima Fabiane S , Zambrano Mauricion , Del Brutto Oscar H
Published: October 2018

Background:
Stroke burden is a leading cause of disability on developing countries. However, there are no studies assessing the impact of previous non-fatal strokes on all-cause mortality in rural areas of Latin America, where living conditions and health care access are different than in urban centers. Using a population-based prospective cohort study (The Atahualpa Project), we aimed to assess the influence of non-fatal stroke on all-cause mortality in community-dwelling older adults living in a remote rural setting.

Methods:
Individuals aged ≥60 years with a non-fatal stroke were detected during yearly door-to-door surveys by the use of validated questionnaires and corroborated by a certified neurologist. Deaths occurring during the follow-up were identified from annual surveys, death certificates review, and other overlapping sources. Univariate tests for equality of survivor functions were used to estimate differences between observed and expected deaths for the presence of a non-fatal stroke. Survival analyses were conducted by the use of the mortality incidence rate ratio (IRR) and by Cox proportional hazard models with subsequent estimation of Kaplan Meier survival curves.

Results:
Of 437 individuals aged ≥60 years enrolled during a 5-year period, follow-up was achieved in 417 (95%), contributing 1,776 years of follow-up (average 4.3±1.3 years). Forty-five (10.8%) individuals were stroke survivors. Fifty-one deaths were detected, for an overall cumulative 5-year mortality rate of 12.2% (95% C.I.: 8.9 - 15.6). According to log-rank analysis, the ratio of observed versus expected deaths among stroke survivors was 14/5.12 (p=0.0001). Having history of a non-fatal stroke was significantly related to mortality (IRR: 3.38; 95% C.I.: 1.69 - 6.41; p=0.0005). A fully adjusted Cox proportional hazard model showed that non-fatal strokes independently predicted mortality (hazard ratio: 2.18, SE: 0.75; 95% C.I.: 1.11 - 4.28; p=0.024).

Conclusions:
This study shows the importance of a previous non-fatal stroke on the risk of all-cause mortality in inhabitants of a remote rural village. Epidemiological studies assessing the impact of region-specific factors influencing mortality may prove cost-effective for developing preventive strategies.
Abstract WP198: Intracranial Arterial Calcification Predicts Stroke Recurrence: an 11-year Follow-up Study
Authors: Wu Xiaohong , Chen Xiang-Yan , Wang Li , Chu Winnie Chiu-Wing , Ren Li-Jie , Wong Ka-Sing , Abrigo Jill , Leung Thomas Wai-Hong
Published: October 2018

Introduction:
Intracranial arterial calcification (IAC) is frequently observed on brain computed tomography (CT) in stroke patients. However, the association between IAC and stroke recurrence after hospital discharge has received little attention. In this study, we aim to explore the effect of IAC on the long-term stroke recurrence.

Subjects and methods:
We prospectively recruited consecutive patients with ischemic stroke or transient ischemic attack during December 2004 and March 2005 from a population-based stroke registry at Prince of Wales Hospital. Demographic characteristics, stroke risk factors, and stroke etiology were recorded at baseline. IAC volume and IAC Agatston score were both measured on 16-slice CT with a semi-automatic system. All patients were regularly followed up for stroke recurrence till July 2016.

Results:
Total 694 patients (age 71.6±12.4; male sex 50.3%; median follow-up period 8.8 years) were followed up. Stroke recurred in 156 patients (22.5%). Multivariate Cox proportional hazard model found higher IAC Agatston score was predictive factor for both recurrent stroke (HR per 1-SD increment 1.301; 95% CI, 1.084-1.561,
p
=0.005) and stroke death (HR per 1-SD increment, 1.441; 95% CI, 1.061-1.956,
p
=0.019). In addition, among different stroke etiological subtypes, IAC Agatston score was independent risk factor of stroke recurrence for index small-vessel occlusive stroke patients (HR per 1-SD increment, 1.674; 95% CI, 1.061-2.639,
p
=0.027).

Conclusions:
Quantitative-evaluated IAC scores can predict long-term stroke recurrence and stroke death.
Abstract WP201: Stroke Patients With Atrial Fibrillation Detected by 72 hour- versus Prolonged ECG-monitoring
Authors: Weber-Krueger Mark , Gelbrich Götz , Liman Jan , Hamann Gerhard F , Kermer Pawel , Gröschel Klaus , Wachter Rolf
Published: October 2018

Background:
Detecting concealed paroxysmal atrial fibrillation (pAF) is a major focus in the workup of ischemic-stroke-patients. The minimal ECG-monitoring for stroke patients was recently expanded from 24 to 72 hours. However, it has been shown that even more prolonged monitoring reveals further pAF-cases. Our aim was to determine, whether known predictors for underlying pAF differ between stroke patients with AF that occurs on shorter (72h) or more prolonged ECG-monitoring (>72h).

Methods:
The Find-AF
RANDOMISED
-trial (NCT01855035) evaluated 3x10-day Holter-ECG vs. standard-care in patients > 60 years with acute ischemic strokes with the primary endpoint of novel pAF after 6 months. In this subanalysis we included only patients in the intervention arm. We compared relevant clinical characteristics (age, gender, body-mass-index = BMI and stroke severity, expressed by the Natrional Institute of Health Stroke Scale, NIHSS-Score), echocardiographic signs of left atrial (LA) dilation (LA diameter, left atrial volume index), blood levels of brain natriuretic peptide (BNP) and rates of supraventricular ectopic activity (longest supraventricular, SV-runs and atrial premature beats, APB) during the AF-free intervals of the first 10-day-Holter-ECG.

Results:
402 patients were initially included, 200 in the intervention were analyzed. Baseline characteristics including age (72 65;80 vs. 72 years, 65;76; p = 0.227), gender (55.6 % females vs. 40.5 %; p = 0.149) and NIHSS-Score (4, 2:9 vs. 3, 1;5; p = 0.069) were similar between patients with and without AF. Those with pAF showed significantly larger left atria (LAVI 38.95 ml/m
2
36.13;55.56 vs. 33.3, 26.6;43.5; p = 0.019), longer SV-runs (20, 13;30 vs. 13, 9;20; p = 0.007), more frequent APB/h (19.73, 2.45;47.5 vs. 1.82, 0.53;14.1; p < 0.001) and increased BNP-levels (56 ng/l 30;194 vs. 25, 11;57; p < 0.001). However, we found no significant differences between those with AF detected during standard (72 hour-) and prolonged (>72 hour-) ECG-monitoring.

Conclusions:
There are no relevant characteristic differences between patients with AF detected during standard 72-hour- and prolonged ECG-monitoring.
Abstract WP206: Short-Term Risk of Ischemic Stroke After Detection of Left Ventricular Thrombus on Cardiac Magnetic Resonance Imaging
Authors: Merkler Alexander , Alakbarli Javid , Gialdini Gino , Navi Babak B , Goyal Parag , Kamel Hooman , Weinsaft Jonathan W
Published: October 2018

Introduction:
The risk of ischemic stroke in patients with evidence of left ventricular (LV) thrombus on cardiac magnetic resonance imaging (MRI) is uncertain.

Methods:
We performed a retrospective cohort study of patients who underwent cardiac MRI for evaluation of cardiomyopathy or myocardial ischemia between 2007-2016. Using a departmental registry, we identified all hospitalized patients with cardiac MRI evidence of LV thrombus. In a 2:1 ratio, we created a random sample of hospitalized patients who underwent cardiac MRI for similar indications but had no evidence of LV thrombus. We compared the risk of stroke prior to hospital discharge among three groups of patients: (1) those with no evidence of LV thrombus, (2) those with LV thrombus by cardiac MRI but not by echocardiography, and (3) those with LV thrombus by both cardiac MRI and echocardiography. The chi-square statistic was used to compare rates of stroke among the three groups.

Results:
We identified 33 patients with evidence of LV thrombus on cardiac MRI and 66 patients without LV thrombus on cardiac MRI (mean age, 56.8 (±13.1) years). All patients underwent echocardiography. Patients with LV thrombus on cardiac MRI had a higher burden of myocardial infarction than patients without LV thrombus (21.4% versus 8.3%,
P
<0.001), but had similar ejection fractions (28.8% versus 31.1%,
P
= 0.34). Of the 33 patients with LV thrombus on cardiac MRI, 13 also had echocardiographic evidence of LV thrombus. Ischemic stroke prior to hospital discharge occurred in 0 of 66 (0%; 95% Confidence Interval [CI], 0-5.4%) patients without LV thrombus on cardiac MRI, 1 of 20 (5%; 95% CI, 0.1-24.9%) patients with LV thrombus on cardiac MRI but not echocardiogram, and 2 of 13 (15.4%; 95% CI, 1.9-45.4%) patients with LV thrombus by both cardiac MRI and echocardiography (
P
value for comparison among groups, 0.01).

Conclusions:
We found a 5% short-term risk of ischemic stroke in patients with LV thrombus that was not seen on an echocardiogram but was detected on cardiac MRI.
Abstract WP207: Could White Matter Lesion Predict the Risk of Paroxysmal Atrial Fibrillation in Cryptogenic Stroke?
Authors: Song Bo , Deng Wenjun , Fisher Lindsay , Chou I-ying , McMullin David , Silverman Scott , Wang Xiaoying , Lo Eng H. , Xu Yuming , Buonanno Ferdinando S , Ning Mingming
Published: October 2018

Background:
Stroke caused by paroxysmal atrial fibrillation (PAF) can be more severe than other cryptogenic stroke (CS), with higher recurrence rates and requiring different prevention strategies. Therefore, it is important to identify PAF early. Studies showed that age and PR-interval predict PAF, but with only moderate reliability. Additional PAF risk predictors are direly needed to triage cost-effective workup in real time clinical care. Since studies show strong association between white matter lesions (WML) and AFib, we explore whether chronic WML found during acute stroke hospitalization can prospectively predict the risk of PAF after discharge in CS patients.

Method:
Eligible patients were prospectively recruited in accordance with IRB. All patients underwent full cryptogenic stroke workup including MRI/MRA, outpatient cardiac monitor (>30 days), cardiac echo, and hypercoagulable testing.

Results:
Of 1,131 acute ischemic stroke patients enrolled, 126 (11.1%) were diagnosed with first ever CS at discharge. 18 pts were diagnosed with PAF at 1 year after discharge. PAF pts were older, with more incidence of cancer and diabetes, and more severe WML burden (table ). Total Scheltens score independently predicts post-discharge PAF in CS with cut-off value >=6 (sensitivity 76.47%, specificity 62%, p=0.013).

Conclusion:
We found chronic WML burden can prospectively predict later PAF risk in CS stroke patients at acute hospital discharge. To better triage cost-effective outpatient PAF workup, readily available imaging characteristics from acute hospitalization may be an important adjunct for future PAF risk prediction. A larger cohort with additional risk factors is needed to improve prospective prognostic value of WML in the prediction of PAF.
Abstract WP21: Different View on Clinical Application of Tirofiban After Mechanical Arterial Recanalization in Acute Ischemic Stroke
Authors: Geng Xiaokun , Cheng Zhe , Singh Rasanjeet , Du Huishan , Ding Yuchuan
Published: October 2018

Tirofiban, an antiplatelet drug and glycoprotein-IIb/IIIa inhibitor, widely used in cardiovascular events, appears to be safe and effective in cerebrovascular stroke. However, its efficacy post-endovascular therapy raised concern due to an association with increased risk of fatal intracerebral hemorrhage (ICH) and poor outcome in ischemic patients (Kellert et al. 2013). The success of 5 randomized clinical trials in stroke therapy in 2015 utilizing new generation endovascular intervention prompted this study of continuous intravenous administration of Tirofiban after thrombectomy with the Solitaire stent, one of the two new devices, in patients with acute ischemic stroke. A consecutive series of patients (n=28) who received Solitaire stent thrombectomy from January 2017 to the present was enrolled. 22 of the 28 patients were eligible for intravenous Tirofiban treatment for 24 h after receiving endovascular therapy. 6 patients were excluded because of no vessel recanalization, vessel recanalization achieved by other devices, or ICH after endovascular therapy. The incidence of symptomatic ICH and death was recorded. The number of thrombectomy attempts and device manipulation time within vessels were measured as potential markers for endothelial damage. The NIH stroke and modified Rankin scales were assessed at 7 days and 3 months, respectively. In all 22 patients who received Tirofiban after endovascular therapy, none had symptomatic ICH nor died from treatment. Successful recanalization rate (TICI≥2b) was achieved in 18 (86.4%) of 22 patients after endovascular therapy. As compared to the study by Kellert et al., the lower average device passages (1.2 vs 2.0) and short device manipulation time (56 vs 104 min) together suggested less endothelial damage. Of our patients, 77.3% showed neurological improvement at 7 days and 59.1% patients had favorable outcomes with a Modified Rankin scale of 0 to 2 at 3 months. These favorable outcomes were similar to those achieved in the 5 positive randomized trials. In conclusion, the continuous application of Tirofiban post-Solitaire stent thrombectomy appears to be safe and effective in acute ischemic stroke. Reduced endothelial damage may play a key role in clinical outcomes with Tirofiban application.
Abstract WP212: Rapid Point-of-care Nr2 Peptide Test for Acute Stroke Detection
Authors: Weissman Joseph D , Ponamarev Grigory , Heath Rozalyn , Boiser Joey C , Dambinova Svetlana
Published: October 2018

Background and Objectives:
Time delay is a challenge in using biomarkers in guiding acute ischemic stroke (IS) therapy. Therapeutic decisions must be made quickly and standard blood draws with transport to a laboratory results in delay of results and possible degradation of biomarkers. We report the initial experience with rapid nanoparticle lateral flow (nLF) tests on fingerstick blood samples for the NR2 peptide (NP), a fragment of the NMDA receptor. This extends our prior research (PLoS ONE, 2012, 7, e42362).

Methods:
Capillary blood (20 microliter) withdrawn less than 15 hours after IS onset was developed within 5 min yielding test (T) and control ( C ) bands in a nLF assay (DRD/CIS Biotech, Inc, Atlanta, GA). An Epson V700 scanner and ImageJ software (Rasband, W.S., ImageJ, U. S. NIH, Bethesda, Maryland) were used to quantify the LF bands. Plasma measurements of NP using MP-ELISA were carried out as well.

Patient Selection:
Patients (n=13) with thrombotic and embolic stroke and controls (n=16) with non-vascular disease of the CNS and healthy volunteers were enrolled. Diagnosis of ischemic stroke was confirmed by clinical evaluation and neuroimaging (CT, MRI and transcranial doppler). Increased NR2 peptide was detected in plasma of 9/13 patients with IS, i.e., the rapid test showed 2 lines (control and test). In some patients both lines are visualized equally others the T-line is stained less intensively. In the control group there is only one band (16/16) Elevated NP correlated with new lesion areas on DWI/MRI with a slope of ~ 1ng per 5 ml stroke volume.

Conclusions:
NR2 peptide is elevated with IS and may be detected by rapid fingerstick tests. Plasma NR2 peptide levels correlate with stroke volume.
Abstract WP213: Discovery of a Serum Protein Panel to Stratify Stroke and Stroke-Mimic Patients
Authors: Daubenspeck A A , Bottomley M , Olson J E
Published: October 2018

Introduction:
A rapid diagnostic tool that appropriately triages stroke and non-stroke patients would decrease patients’ time to treatment and therefore lower the risk of morbidity. Single blood protein biomarkers for stroke have not shown clinical utility. Our objective in this biomarker discovery study is to examine a wide array of proteins to identify a panel that stratifies stroke patients from stroke-mimicking patients.

Hypothesis:
Serum from ischemic stroke patients contains proteins identified by the SOMAscan biomarker discovery assay that can stratify stroke from non-stroke patients.

Methods:
Patients presenting to the emergency department with stroke-like symptoms had peripheral blood drawn upon arrival according to Stroke Alert protocols. Once informed consent was obtained, serum was analyzed with the SOMAscan assay to quantify the expression of 1305 proteins. These data were analyzed using the semi-supervised machine learning algorithm, random forest analysis (RFA), to determine a combination of proteins which best predicted the final patient discharge diagnosis.

Results:
Twenty-two stroke patients, 9 transient ischemic attack (TIA) patients, and 23 patients with other stroke-mimicking symptoms participated in the study. Normal age- and sex-matched serum controls were obtained commercially. RFA identified four panels encompassing a total of nine proteins to stratify patients between the stroke, TIA, other stroke mimic, and control groups. Applying these panels to the same training set of patient data, one panel of two proteins distinguished stroke from stroke-mimics with a sensitivity of 50% and specificity of 100%. A second panel of three proteins identified stroke from non-stroke patients with a sensitivity of 78% and specificity of 95%. A provisional patent application describing these panels is underway.

Conclusion:
Ischemic stroke patients and stroke-mimic patients exhibit a differential expression of serum proteins at the time of clinical presentation. The simultaneous analysis of two or three proteins in a biomarker panel exhibits high specificity and may be clinically useful as a stroke “rule in” tool for emergency personnel. This would facilitate triage and avoid inappropriate treatment of non-stroke patients.
Abstract WP216: External Validation of Pomona Large Vessel Occlusion Scale at Aurora Health Care System (AHCS)
Authors: Panichpisal Kessarin , Chohan Adil , Villar Paul , Singh Maharaj , Babygirija Reji , Hook Mary , Matyas Sharon , Kojis Nathaniel , Sajjad Rehan , Wolfe Thomas , Richard Rovin A
Published: October 2018

Background:
The Pomona scale was developed to predict large-vessel occlusions (LVO) in patients with acute ischemic stroke (AIS). The original study showed a high accuracy of this scale. We sought to externally validate the Pomona scale in an independent cohort.

Methods:
Pomona scale includes 3 items: gaze deviation, expressive aphasia and neglect, each given 1 point when present. We retrospectively reviewed a large cohort of all acute stroke patients who presented within 24 hours after onset at AHCS ( 14 hospitals) between January 2015-December 2016. We calculated Pomona scale, the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), the Prehospital Acute Stroke Severity Scale (PASS) for all patients. The predictive performance of all scales and several National Institute of Health Stroke Scale (NIHSS) cut offs (≥4, ≥6, ≥8, ≥10) were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (M1), or basilar arteries.

Results:
Among 2183 AIS patients, 1410 had vascular imaging and were included in the analysis. LVO was detected in 171 (12%). Pomona scale ≥ 1 had comparable accuracy to predict LVO as Pomona scale ≥ 2, the CPSS, and NIHSS ≥6, ≥8, and ≥10. Pomona scale ≥ 1 had higher accuracy than VAN, LAMS, PASS and NIHSS ≥ 4 (area under the receiver operating characteristics curve: Pomona ≥ 1= 0.77 as a reference; VAN=0.66,
P <
0.001; LAMS ≥ 4 = 0.61,
P <
0.001, PASS ≥ 2= 0.68,
P <
0.001 and NIHSS ≥ 4,
P=
0.0025). A Pomona scale ≥ 1 had sensitivity of 0.79, specificity of 0.76 to predict LVO, positive predictive value of 0.31, and negative predictive value of 0.96 for the detection of LVO versus Pomona scale ≥ 2 of 0.57, 0.91, 0.47, and 0.94 and CPSS ≥ 2 of 0.64, 0.87, 0.41 and 0.95.

Conclusion:
In our large stroke network cohort, the Pomona scale has promising sensitivity, specificity and accuracy to predict LVO. Future prospective studies in both prehospital and emergency room settings are warranted.
Abstract WP22: Collateral Score and Outcome After Endovascular Treatment for Basilar Occlusion
Authors: Dias Francisco , Castro-Afonso Luis , Zontin Maria Clara , Alves Frederico , Martins Rui , Libardi Milena , Camilo Millene , Cougo Pedro , Nakiri Guilherme , Barreira Clara , Monsignore Lucas , Abud Daniel , Pontes-Neto Octavio M
Published: October 2018

Introduction:
Basilar artery occlusion (BAO) is a rare stroke subtype with high morbidity and mortality rates. Best reperfusion strategy is still somewhat controversial and is currently under investigation in multicenter randomized trials. We aim to describe outcomes of BAO patients submitted to mechanical thrombectomy in a comprehensive stroke center in Brazil and analyze which previous published computed tomography angiography (CTA) collateral score better predicts functional outcomes.

Methods:
Retrospective analysis of consecutive BAO patients from a prospective stroke registry. BAO was diagnosed through CTAs, which were also used to evaluate the
Posterior Circulation Collateral Score
(PC-CS), the
Basilar Artery on Computed Tomography Angiography
(BATMAN) scores and also for the presence of both posterior communicating arteries. A favorable outcome was defined as a mRS ≤3 at 90 days. After univariate analyses, multivariate logistic regression was used to identify if any collateral score independently predicts a favorable outcome. We also used ROC curves and C-statistics for score comparisons.

Results:
Between January/2011 and April/2017, 27 (85% male) BAO patients with median NIHSS of 26 (IQR:15-32) were identified. Twenty-five (93%) patients were treated with a stent-retriever or an aspiration device, and only 2 (7%) patients were treated with basilar artery angioplasty and stenting. Recanalization rate was 85% and only 1 (3.7%) patient had a symptomatic hemorrhagic transformation. Favorable outcomes were reached in 10 (37%) patients at 90-days and mortality rate was 37%. In univariate analysis, female sex, NIHSS, onset-to-groin time and PC-CS predict favorable outcomes. In multivariate analysis, only PC-CS (OR=1.69;95%CI:1.10-2.60;p=0.016) and the baseline NIHSS (OR=0.84;95%CI:0.77-0.93;p=0.001) remained as independent predictors of favorable outcomes. The PC-CS AUC for favorable outcome was 0.80 (95%CI:0.62-0.98;p=0.012).

Conclusions:
Mechanical thrombectomy seems to be a promising strategy for patients with acute BAO. Collateral flow assessment using the PC-CS is an independent predictor of favorable outcomes among acute BAO patients treated with mechanical thrombectomy.
Abstract WP229: The Impact of EMS Directly Transporting Patients With Suspected Acute Ischemic Stroke to Comprehensive Stroke Centers in South Florida
Authors: Mueller-Kronast Nils , Marulanda-Londono Erika T , Wang Kefeng , Dong Chuanhui , Gardener Hannah , Gutierrez Carolina , Asdaghi Negar , Antevy Peter , Scheppke Kenneth , Yavagal Dileep , Mehta Brijesh , Kaushal Ritesh , Pepe Paul E , Hodges Wayne , Romano Jose G , Sacco Ralph L , Rundek Tatjana ,   FL-PR CReSD Investigators and Collaborators
Published: October 2018

Background:
After endovascular therapy (EVT) became standard of care for acute ischemic stroke (AIS) in 2015, emergency medical services (EMS) in 3 urban southeast Florida counties modified their transport protocols for suspected AIS. In 2015, Broward (BC) and Palm Beach counties (PBC) phased in EMS transport of all stroke alerts to state-attested comprehensive stroke centers (CSC). Miami-Dade (MDC) adopted a severity-based protocol.

Methods:
The impact of EMS policy changes was assessed using the AHA Get with the Guidelines-Stroke data prospectively collected for the Florida-Puerto Rico Stroke Registry involving 35,794 AIS cases in the 3 counties with 27 CSC between 2010 and 2016.

Results:
The percent of patients transported directly by EMS from scene to CSCs in BC and PBC rose from 34% and 13% during 2010, to 97% and 86%, respectively, in 2016 (p=0.002). In MDC, it increased from 62% to 77%. In 2016, the percentage of AIS patients that presented to CSC as transfers from primary stroke centers (PSC) was 5% in BC, 8% in PBC, and 12% in MDC. Of all patients receiving IV tPA in 2016, 81% were transported by EMS and 87 % of IV tPA treatment was administered in a CSC. From 2010 to 2016, IV tPA treatment increased from 8% to 18% in CSC vs. 8% to 12% in PSC (p=0.41). By 2016 the mean door to needle time was 13 min shorter in CSCs (p<0.001). Mean interval from symptom onset to IV tPA (OTT) decreased to 112 min in CSC vs. 125 min in PSC (p=0.047) and 19% of patients at CSCs had an OTT in the “golden hour” compared to 11% at PSCs. In 2016 the mean onset to arrival in patients transferred from PSC to CSC for EVT was 109 min longer than in those directly transported to CSC. The percentage of patients receiving EVT increased overall to 6%, with 9 CSC reporting greater than 10% EVT, 5 CSC greater than 15%, and 2 greater than 20% EVT for all AIS cases.

Conclusion:
Modifying EMS policies to transport most suspected AIS patients directly to CSCs was associated with higher rates of IV tPA treatment, shorter intervals to IV tPA after symptom onset, faster arrival times for EVT evaluation and higher rates of EVT compared to patients triaged to PSCs. Based on these findings, directly transporting suspected AIS patients to CSC may be a successful strategy to expedite stroke care interventions in urban centers with high CSC density.
Abstract WP230: Safety of Intravenous Thrombolysis in Telestroke and Impact of an Acute Stroke Training Curriculum
Authors: Girotra Tarun , Kohli Disha , Lowe Forrest , Debenham Ellen , Holmstedt Christine , Banerjee Chirantan
Published: October 2018

Background:
Stroke telemedicine has the potential to improve access to intravenous thrombolysis nationwide among acute ischemic stroke (AIS) patients. No formal training or credentialing process has been established nationally for neurologists to provide telestroke care. Our academic Remote Evaluation of Acute Ischemic Stroke (REACH) program has been delivering telestroke care for almost 10 years. Every telestroke provider neurologist undergoes a training curriculum prior to providing telestroke care.

Aim:
1. To demonstrate safety of IV tPA in AIS patients treated via telestroke. 2. To assess impact of acute stroke training curriculum by comparing safety outcomes in patients treated by fellowship trained stroke neurologists (FTSN) versus other neurologists (ON).

Methods:
All REACH consults from May 2008 to July 2017 were included in our analysis. Patients were classified based on whether remote evaluation was performed by FTSN or ON. Symptomatic ICH (sICH), asymptomatic ICH (aICH), and any ICH rates were determined overall, and in the 2 groups. Fisher’s exact test and Wilcoxon rank-sum test were used to compare categorical variables and continuous variables respectively.

Results:
Total number of telestroke consults performed were 10,904 (7644 by 12 FTSN and 3260 by 13 ON respectively). IV tPA was given to 1446 (18.91%) patients in FTSN and 569 (17.45%) patients in ON group respectively (p=0.07). Symptomatic ICH occurred in 59 (2.92%) patients overall, and was comparable between the two groups [42 (2.90%) vs 17 (2.98%), p-value 0.88]. Asymptomatic ICH occurred in 121 (6%) patients, 77 (5.32%) of whom were in FTSN group and 44 (7.73%) patients in ON group (p-value 0.04). Any ICH occurred in 180 patients, 119 (8.22%) and 61 patients (10.72%), p-value 0.08 respectively.

Discussion:
Our study demonstrates safety of IV tPA delivery via telestroke in AIS patients. There were no differences in IV tPA administration, sICH and any ICH rates between FTSN and ON providers, but the aICH rate was higher among ON. The comparable safety outcomes between ON and FTSN in our study are likely attributed to an AIS training curriculum at credentialing. National standardized credentialing training curricula for telestroke providers may help improve outcomes in AIS patients.
Abstract WP233: A Pilot Study Validating Video-based Training on Pre-hospital Stroke Recognition
Authors: Brown Aliza T , Wei Feifei , Onteddu Sanjeeva , Bianchi Nicolas , Skinner Robert , Culp William
Published: October 2018

Introduction:
Delays in recognizing stroke during pre-hospital emergency medical system (EMS) care may affect triage+transport time to appropriate stroke ready hospitals and may preclude patients from receiving time dependent treatment. All EMS transports in a large urban area in the stroke belt were evaluated for transport destinations, triage+transport time and stroke recognition following distribution of an educational training video to local EMS services.

Hypothesis:
Following video training local paramedics will improve stroke recognition, shorten triage+transport time, and increase stroke transports to primary stroke centers (PSC) of care.

Methods:
A training module (<10 min) containing a stroke scene scenario, instruction on the Cincinnati Prehospital Stroke Score (CPSS) and the Los Angeles Prehospital Stroke Score (LAPSS) and ‘where to transport’ stroke patients was distributed and viewed by 94 paramedics. Data was collected from February to October 2016. Stroke recognition was determined from one PSC hospital’s confirmation of EMS delivered patients (site A). Stroke recognition percentages from site A collected in 2014 were used as baseline.

Results:
A total of 35,207 emergency 911 response transports were made with a total of 506 (1.4%) paramedic identified strokes. Average triage+transport time for stroke transports was 33 +/- 0.7 minutes. The PSC hospitals received a 5% increase in stroke transports and the non-specific care facilities decreased by 7%. The PSC stroke confirmation totaled 130 transports with 140 suspected strokes by paramedics and 71 of 130 confirmed strokes correctly identified by paramedics (positive predictive value of 50.7%, sensitivity of 54.6%). By the third month following training, recognition percentages increased from 54% at baseline to 73%. At five months, percentages of correct stroke identification had dropped to pre-training levels.

Conclusion:
The training improved stroke recognition by an additional 19% with follow-up training recommended at five months.
Abstract WP236: Utility of the Los Angeles Motor Score in Predicting Large Vessel Occlusions
Authors: Brandler Ethan S , Perez Karol , Boddepalli Raja , Thode Henry C
Published: October 2018

Background:
Studies have documented the effectiveness of endovascular therapies in large vessel occlusions (LVO). Since not all primary stroke centers are capable of delivering endovascular care, emergency medical services are now tasked with routing such patients who have large vessel occlusions to facilities capable of delivering such therapies. There are patient specific and and emergency medical system issues to a decision to bypass a local primary stroke center in favor of transport to an comprehensive center. Few of the LVO identification tools have been validated by paramedics. We sought to describe the utility of the Los Angeles Motor Score (LAMS) and of other physical findings for predicting the presence of a LVO in a population of stroke code patients examined by paramedics and EMTs.

Methods:
We analyzed a convenience sample of stroke code patients presenting to a tertiary care center ED. Paramedics examined patients using the LAMS. Paramedics were also asked to assess for problems including leg weakness, visual disturbances, altered level of consciousness, and language abnormalities (dysarthria, aphasia). We calculated operating characteristics of a LAMS score of ≥ 4 and of a modification of the LAMS to include speech disturbance, and performed a stepwise logistical regression on the other potential physical exam elements that might predict large vessel occlusion.

Results:
A total of 332 subjects mean age 68 (±SD17), 53% female were examined by paramedics. One hundred forty (42%) had a stroke, and of these 71 (21%) had an LVO. A LAMS ≥ 4 identified stroke and large vessel occlusions with sensitivity of 28% and 38% and specificity of 95% and 92% respectively. Using LAMS of 1 to 3 with an abnormal speech test, 12 additional strokes and 8 LVOs were identified with resultant sensitivity and specificity of 36% and 94% and 49% and 89% for stroke and LVO respectively.

Conclusion:
Performed by paramedics and EMTs in an enriched stroke code population, the LAMS score can be used to identify LVOs with high specificity. More importantly, use of the modified LAMS results in an NPV of 87% with a PPV of 56%. This suggests that application of the modified rule would capture many cases of LVO while transporting few patients longer distances unnecessarily.
Abstract WP241: Achieving Door-to-needle Times in Under 30 Minutes at a Community Hospital Utilizing a Stroke Team "Quarterback."
Authors: Ovando Renee M , Phillips Michelle S , Baraban Elizabeth , Tarpley Jason W
Published: October 2018

Background and Purpose:
IV tissue plasminogen activator (tPA) or alteplase is the only FDA-approved medication for acute ischemic stroke. For those eligible, it is recommended to be given within 60 minutes of ED arrival. Hospitals are recognized for more rapid delivery within 45 minutes as it is well reported that faster times correlate with improved functional outcomes. Apart from ED staff, a hospital stroke quarterback (neurologist or stroke RN), when available, responded to code strokes, orchestrated rapid interdepartmental flow, and served as a liason to EMS, bystanders and family, ED, Radiology, Telestroke and other and other team members. This study compared the effect of a stroke quarterback on Door-to-Needle (DTN) times and outcomes when compared to times when this added resource was not at bedside.

Methods:
Utilizing data from a single facility’s Stroke tPA database, a retrospective data analysis was performed reviewing DTN times for all patients treated with IV alteplase from December 2015 to July 2017. Secondary measures included door to CT times, length-of-stay (LOS), Modified Rankin Scale (mRS) score at discharge and tPA related-complications. Data were analyzed using Mann Whitney U or chi-square tests, as appropriate. Significant results and associated
p
-values are reported.

Results:
A total of 60 patients were included in the primary analysis, 61.7% (n=37) of patients were treated with a stroke quarterback at bedside, and 38.3 % (n=23) of cases were managed without. The median DTN with a stroke quarterback was 28.0 minutes [interquartile range (IQR)=19-36], whereas those managed without was 64.0 minutes [IQR=50-89] (U=78.5,
p
<.001). Fifty-four percent of patients treated with stroke quarterback met DTN times under 30 minutes. The median door to CT time was also significantly shorter (9 minutes [IQR=6-18] versus 18.5 minutes without [IQR=10-27] (U=213.5, p=.005). There were no significant differences in LOS, mRS or complications between the 2 groups.

Conclusion:
The addition of a dedicated stroke team quarterback resulted in significantly shorter time to acute stroke treatment with thrombolysis. The majority of cases were treated in under 30 min
Abstract WP244: Current Status and Issues in Prehospital Care for Stroke in Japan: A Nationwide Fire Department Questionnaire Survey
Authors: Arimura Koichi , Kurogi Ai , Onozuka Daisuke , Anzai Toshihisa , Okayama Satoshi , Okuchi Kazuo , Kada Akiko , Kitazono Takanari , Shiokawa Yoshiaki , Nakashima Naoki , Nishimura Kunihiro , Hagihara Akihito , Higashi Takahiro , Yasuda Satoshi , Yoshimura Shinichi , Nishimura Ataru , Sakamoto Tetsuya , Iihara Koji
Published: October 2018

Background and purpose:
In the rapidly aging society of Japan, improvement of the emergency medical care system for stroke is an urgent concern. In prehospital care for stroke, appropriate triage, selection of the delivery facility, and decreased transport time contribute directly to prognosis. The standard treatment for acute ischemic stroke (AIS) has changed dramatically. With the introduction of new thrombectomy devices, proper placement of comprehensive stroke centers (CSCs) should be reconsidered. Accordingly, a nationwide survey is needed to develop an efficient prehospital care system. The aim of this study was to elucidate problems in prehospital care for stroke in Japan, using a nationwide fire department (FD) questionnaire survey.

Materials and methods:
We conducted a questionnaire survey of 733 FDs in Japan with the cooperation of the Japanese Society of Emergency Medicine and the Emergency Planning Office of the Fire and Disaster Management Agency. The questionnaires evaluated utilization status of the Prehospital Stroke Life Support (PSLS) protocol and prehospital stroke scale (PSS), awareness of standard treatment with new devices, information on delivery facilities and transportation, use of information and communication technology (ICT), and the retraining system for paramedics.

Results:
Data obtained from 664 FDs (91%) were analyzed. The PSLS protocol and PSS were used by 47.2% and 59.6%, respectively. Surprisingly, only 35.6% of FDs had knowledge about the latest treatment for AIS, and half of the FDs did not have an opportunity to learn about treatment. The proportion of FDs with a CSC in their jurisdictions was decreased in rural areas compared with urban areas (19.2% vs. 49.8%). However, helicopter transportation and ICT were not adequately utilized even in rural areas. Only half of the FDs urged paramedics to attend a PSLS course.

Conclusion:
We demonstrated problems with prehospital care for stroke in Japan using a nationwide FD questionnaire survey. Placement of CSCs, adequacy of the transportation system, and communication between physicians and paramedics should be reevaluated.
Abstract WP248: Insights Into Improving Care: Established Infarct and No Large Vessel Occlusion Are the Major Causes to Forego Endovascular Therapy Following Transfer
Authors: Morey Jake , Dangayach Neha , Mocco J , De Leacy Reade , Oxley Thomas , Kellner Christopher , Shoirah Hazem , Tuhrim Stanley , Fifi Johanna T
Published: October 2018

Introduction:
Endovascular therapy (ET) has emerged as the standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS) following the positive outcomes from multiple recent randomized trials. This has resulted in an increase in the number of LVO AIS patient transfers to comprehensive stroke centers (CSC). Not all transfers result in ET, and futile transfers may overload CSCs with poor cost benefit ratio. Thus an analysis of the major reasons to forego ET is warranted.

Hypothesis:
The major causes to forego ET in LVO AIS patients transferred for treatment in an metropolitan setting are a product of the local stroke systems of care and causes that may be mediated with appropriate imaging and EMS triage protocols will be identified.

Methods:
A retrospective analysis of data prospectively collected data between January 1, 2015, and July 31, 2017 was performed on 171 patients whom were transferred from outside hospitals (OSH) to a CSC in a metropolitan area. Of these patients, 63 (37%) were deemed ineligible for ET. The causes to forego ET in these patients were identified and cross referenced with factors that could be changed such as imaging protocols, transfer times, and proximity to a CSC.

Results:
The major causes to forego ET were established infarct due to intra-transfer ASPECTS decay (36%) and no LVO (29%). Other causes included: patient too mild or clinically improved (22%), post-tPA hemorrhage (5%), outside time window or randomized to medical management (3%), and other, such as heart attack, seizure, or gastrointestinal bleed (5%). Of the no LVO cohort, 14/18 patients (78%) had no CTA imaging until CSC arrival. The established infarct cohort had a median OSH arrival to CSC arrival time interval of 165 minutes (IQR=130-229.5). Proximity to a CSC from the OSHs in the study ranged from 1 to 9.6 miles with a travel time of 7 to 30 minutes.

Conclusions:
Development of established infarct and no LVO were major causes of no ET for transfer patients. These can be mediated by stroke system changes to minimize patient transfers, such as EMS triage to CSC for LVO, with minimal impact on initial arrival time in this urban setting. In addition, the implementation of timely computed tomography angiography (CTA) imaging at OSHs should help reduce futile transfers.
Abstract WP255: Omega-3 Fatty Acids as a Treatment for Experimental Ischaemic Stroke: A Systematic Review and Meta-analysis
Authors: Fulton Lily , McCann Sarah , Macleod Malcolm , MacLeod Mary J , Thies Frank
Published: October 2018

Introduction:
The number of stroke patients arriving at hospital within a therapeutic timeframe is increasing, enabling earlier and more successful intervention with thrombolysis and thrombectomy. Despite promising animal data, no neuroprotectants have translated into clinical practice. Brain tissue contains a high amount of polyunsaturated fatty acids, particularly docosahexaenoic acid (DHA), an omega-3 fatty acid essential for normal brain growth and cognitive function. As DHA plays a critical role in neuronal survival and synaptic function, and is also a potent modulator of brain inflammation, it is a strong candidate for a successful neuroprotectant in stroke.

Aims:
We therefore aimed to summarise the current evidence for omega-3 fatty acids as a treatment for experimental acute ischaemic stroke.

Methods:
A systematic literature review of papers reporting omega-3 administration in animal models of acute stroke was conducted using the CAMARADES systematic review facility (SyRF). 1173 titles were screened, 168 abstracts reviewed and data extracted from 15 studies. Data were extracted manually, and collated, organised and analysed within CAMARADES. Measures of study quality were recorded, reflecting current STAIR recommendations for pre-clinical studies. Pre-defined endpoints extracted included mortality, infarct volume and neurobehavioural score.

Results:
DHA reduced infarct volume with an effect size of 48.5%, (95% CI 32.2 - 65.5) compared to control treatments. Neurobehavioural score was improved by 34.8%,( 95% CI 21.8 - 47.7) in DHA treated animals. There was a decrease in mortality of 61% for DHA treated animals (OR 0.39, 95% CI 0.21-0.77(12 studies, no heterogeneity)). All studies used male animals, and no studies co-administered alteplase. Composition of omega-3 preparations was a source of significant heterogeneity (P<0.05). Post hoc analysis showed laboratory group was also a significant source of heterogeneity.

Conclusions:
Current evidence suggests that DHA administration significantly improves outcome and decreases mortality in animal models of acute ischaemic stroke, providing support for further translational studies.
Abstract WP257: Microrna-20a-3p is Neuroprotective in Both Males and Females in an Ischemic Stroke Model
Authors: Selvamani Amutha , Sohrabji Farida
Published: October 2018

Background:
Previous studies in our lab have shown that neuroprotective miRs let-7f and mir-363-3p were both only protective in females but not males. In an effort to identify a more universal miRNA-based therapeutic, a large scale profiling of astrocytic microRNA (miR) in young and middle aged male and female rats was conducted. This approach revealed that members of the mir17~92 cluster were regulated by age and sex. Mir-20a-3p, a member of this cluster, was inversely related to infarct volume, such that adult females, who display the smallest infarct volumes, had the highest expression of miR-20a-3p, while mir20a-3p was virtually absent in middle-aged females. Few validated targets of mir20a-3p are identified, however matrix metalloproteinases (MMPs) are ‘predicted’ targets of this miRNA. In view of the evidence that MMPs exacerbate blood brain barrier permeability, we hypothesize that increasing mir20a-3p expression would be neuroprotective. Therefore, the present study was designed to determine if mir20a-3p was mechanistically related to stroke outcomes.

Methods:
Young males (5 mo) and middle-aged female (12 mo) rats were subject to middle cerebral artery occlusion (MCAo) by stereotaxic injection of endothelin-1. At 4h post-stroke, animals received a tail-vein injection of miR-20a-3p or scrambled control. Adhesive removal test was performed pre and post MCAo to assess motor deficits. All animals were terminated at 5d post MCAo and the brains processed for infarct analysis by standard histological procedures.

Results:
Cortico-striatal infarct volumes at 5d post stroke were significantly reduced in the miR-20a-3p treated young males and middle-aged females. In young males, infarct volume was reduced by 24%, while in middle-aged females mir20a-3p treatment reduced infarct volume by 47% as compared to age-matched controls (p ≤ 0.05). Sticky tape test indicated significant motor recovery post-stroke in the contralateral limb in miR-20a-3p mimic treated groups as well.

Conclusion:
Collectively, the data suggests that exogenous post stroke miR-20a-3p treatment is more universally neuroprotective as compared to other miRNA tested previously. These findings also highlights a potential for astrocyte-targeted treatment options for stroke.