bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP239: Stroke Mimics Treated with Thrombolysis: A Single Center Experience
Authors: Mehta Sonal , Vora Nirav , Allam Hesham , Alawi Aws , Koehne Jennifer , Alobaidi Fahad , Kaushal Ritesh , Cruz-Flores Salvador , Alshekhlee Amer
Published: March 2022

Background:
Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. Alternative hypothesis is a higher rate of stroke mimics (SM) among AIS treated in a non-specialized stroke centers and then transferred to comprehensive centers.

Methods:
Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over one academic year. Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge information were collected. We also identified those who were treated in outside facility and then transferred to the tertiary center (i.e. drip-and-ship paradigm). Comparative and adjusted analysis to identify predictors for stroke mimics was performed.

Results:
120 patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = 0.0003), had a slight female preponderance (55% versus 46%; P = 0.46); and more likely to harbor a psychiatric diagnosis (45% versus 9%; P = <0.0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared to 65% of those with AIS (P= 0.02). None of SM had any hemorrhagic complications and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (OR 12.8, 95% CI 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4).

Conclusion:
Drip-and-ship paradigm and the presence of any psychiatric history predict the diagnosis of SM. None of the SM had any thrombolysis related complication and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment of AIS
Abstract WP246: Time of Onset of Acute Ischemic Stroke As Determined by EMS Personnel is Congruent With Physician-Determined Time of Onset
Authors: Tan David K , Connor Lisa , Ford Andria
Published: March 2022

Background:
Finding witnesses for determination of acute ischemic stroke (AIS) time of onset (ToO) is often time-consuming and prolongs door-to-needle time (DNT). Physicians are reluctant to trust the ToO provided by EMS personnel due to little data available on its accuracy. We measured the congruence of EMS-provided ToO relative to physician-determined ToO in suspected AIS patients presenting to the emergency department (ED).

Methods:
From March 2010 to September 2011, research coordinators prospectively collected the EMS-provided ToO for each arriving acute stroke patient. The difference between the EMS-provided ToO and physician-determined ToO was calculated for each patient. Summary statistics were examined for the entire patient cohort and the subgroup of tPA-treated patients.

Results:
Of the 209 acute stroke alerts, the absolute mean difference in EMS- and physician-ToOs was 16 ± 80 min (median [IQR] = 0 [0,0] min). EMS- vs. physician-ToO was congruent within 15 min 87% of the time. Figure shows histogram of absolute differences for the cohort. Of the 46 patients with any difference (≥1 min) in ToO’s, only 2 patients (4.3%) could have been given tPA incorrectly if EMS-provided time had been used (solely based on time-related inclusion criteria for IV tPA up to 4.5 hours). In the subgroup of IV tPA-treated patients (N=40) the absolute mean difference in EMS- and physician-ToOs was 10 ± 27 min (median [IQR] = 0 [0,2.8] min) and were congruent within 15 minutes 88% of the time. None of these patients would have been incorrectly excluded from tPA if EMS-provided times had been used.

Conclusions:
In this convenience sample, EMS-provided ToOs were similar to physician-determined ToOs and. If EMS times had been used in place of physician-determined times, this might have resulted in a 1% tPA error rate. Given that determining the ToO often leads to delays in tPA delivery, further studies are needed to confirm that EMS- ToO’s are reliable for clinical decision-making.
Abstract WP253: Effect Of A Feedback System Of The Formal Diagnosis After Admission On The Emergency Medical Service
Authors: shigehatake yuya , Miyashita Fumio , Hagihara Takaaki , Nagatsuka Kazuyuki , Toyoda Kazunori , Kobayashi Shotai , Minematsu Kazuo
Published: March 2022

Background and Purpose:
Accurate identification of patients with stroke by emergency medical service (EMS) staffs may shorten prehospital delay. We produced an original stroke check sheet with a total 24 items, including vital signs, past history, Cincinnati prehospital stroke scale (PSS), Kurashiki PSS, and provisional diagnosis of stroke subtypes by EMS staffs. We started to feedback the final diagnosis of each patient 2 to 3 weeks after admission to our institute from June, 2011. The aim of this study was to verify effects of this feedback system on the EMS.

Methods:
We retrospectively enrolled 4,013 patients who were admitted to our hospital by using EMS from January, 2010 to March, 2012. We started the diagnosis feedback system to EMS from June, 2011. We divided the patients into 2 groups; those being admitted from January, 2010 to May, 2011 (group A) and those from June, 2011 to March, 2012 (group B). We compared positive predictive value (PPV) of provisional stroke diagnosis and the proportion of patients conveyed within 3 hours after the symptom onset between the 2 groups.

Results:
We collected a total of 2,130 stroke check sheets from conveyed patients; 1,280 in the group A and 850 in the group B. The number of patients with a final diagnosis of stroke was 904 in the group A and 621 in the group B. The number of patients with a provisional diagnosis of stroke at the time of conveyance was 629 in the group A and 406 in the group B. The PPV of a provisional diagnosis of stroke by EMS staff was not different between the 2 groups; 70% in the group A vs. 65% in the group B. Proportion of conveyance within 3 hours after the symptom onset in the group B was as the same level as that in the group A (57% vs. 57%, p=0.964).

Conclusion:
We started to feedback the final diagnosis of each patient 2 to 3 weeks after admission. The improvement was not accepted by the PPV of stroke and the proportion of conveyance within 3 hours after the symptom onset. Our feedback system of the final diagnosis to the EMS has to be improved.
Abstract WP262: Therapeutically Targeting TNFa-S1P Signaling Restores Microvascular Reactivity after Experimental Subarachnoid Hemorrhage
Authors: Yagi Kenji , Lidington Darcy , Meissner Anja , Ai Jinglu , Wan Hoyee , Nedospasov Sergei , Offermanns Stefan , Nagahiro Shinji , Macdonald Robert L , Bolz Steffen-Sebastian
Published: March 2022

Background:
Subarachnoid hemorrhage (SAH) is characterized by an initial hemorrhagic and ischemic brain injury followed by delayed macro- and microvascular constriction. Large-artery vasospasm and enhanced microcirculatory myogenic tone may contribute to delayed cerebral ischemia. Although this implies that therapeutic interventions must specifically correct the SAH-induced myogenic tone enhancement, current therapeutic approaches non-selectively interfere with vasoconstriction and risk disrupting cerebral autoregulation. This may explain why most interventions do not improve clinical outcome. This study identifies the molecular basis for exacerbated cerebrovascular constriction and validates new targets for SAH treatment.

Methods:
Wild-type, tumor necrosis factor α (TNFα) knockout, sphingosine-1-kinase (Sphk1) knockout and inducible, smooth muscle cell-targeted TNFα knockout mice were used. SAH was created by injection of 80 μl of arterial blood into the prechiasmatic cistern. Myogenic tone in the olfactory artery was assessed with a myograph system. Standard procedures for fluorescent immunolocalization, Western blotting and assessment of apoptosis were used.

Results:
SAH increased myogenic tone and vascular wall TNFα expression, without enhancing overall vascular contractility in response to phenylephrine. Knockout of TNFα globally or smooth muscle cell-specifically prevented SAH-induced increased myogenic tone. Inhibition of TNFα-shedding (TAPI, 50 μmol/L) or receptor-binding (etanercept, 10 mg/ml) eliminated SAH-mediated myogenic tone augmentation. Cystic fibrosis transmembrane regulator (CFTR) protein expression was down-regulated in cerebral arteries after SAH, which was abolished by antagonism of TNFα. Genetic mouse models confirmed that S1P signaling mediates the myogenic tone augmentation in SAH. Finally, disrupting TNFα signaling attenuated neuronal apoptosis in SAH animals.

Conclusion:
We identify a novel smooth muscle cell autocrine/paracrine signaling network that augments myogenic tone in SAH. It links TNFα, CFTR and sphingosine-1-phosphate (S1P) signaling. Targeting TNFα and the S1P
2
receptor subtype are potential therapeutic options to improve clinical outcome in SAH.
Abstract WP27: Time to Recanalize an Acute Vessel Occlusion from Groin Puncture Matters Among Patients Selected for Intra-Arterial Therapy based on CT Perfusion Imaging
Authors: Spiotta Alejandro , Vargas Jan , Miranpuri Amrendra , Turner Raymond , Chaudry Imran , Turk Aquilla
Published: March 2022

INTRODUCTION:
Mechanical thrombectomy has an established role in the management of acute ischemic stroke (AIS). We investigate whether procedure time is related to recanalization, intraprocedural complications and functional outcome.

Methods:
A retrospective review was performed of all AIS cases that underwent intra-arterial (IA) intervention between May 25, 2008 and August 7, 2012. Candidacy for IA therapy was determined by CT perfusion imaging irrespective of onset time. Demographics, procedural times, time to recanalization, recanalization status, procedural complications and ninety day outcome defined by modified ranking scale (mRS) were extracted.

Results:
One-hundred and fifteen patients were identified (53% female; mean age 66.5 ± 15 years) with a mean time to treatment 11 hr 16 min and an NIHSS of 15.6 ± 7. Forty-nine patients (42.6%) received intravenous tPA prior to IA therapy. Occlusions involved the anterior circulation in 88% of patients. Mean procedure time for mechanical thrombectomy was 1hr 39 min ± 44 min and ninety-six (83%) received adjunctive IA thrombolysis with tPA. TICI IIB or III was achieved in ninety-four (81.7%) patients with an overall complication rate of 7.8% (9/115). In forty-one patients (35.6%), recanalizations were achieved in less than one hour (‘Immediate Recan’) compared to 64% in which procedures lasted greater than one hour (‘Delayed Recan’). Among those in the ‘Immediate Recan’ group, TICI IIB or greater was achieved in 90% (37/41) as compared to 77% (57/74) in the ‘Delayed Recan’ group. The intra-procedural complication rate was similar between the two groups (7.3% vs. 8.2%). Ninety-day mRS was more favorable among the ‘Immediate Recan’ group, in particular among those achieving a mRS 0-2 (mRS 0=20%, 1-2 = 36.7%, 3-5 = 23.3%, 6=20%) compared to the ‘Delayed Recan’ group (mRS 0=11%, 1-2 = 25%, 3-5 = 38%, 6=25.4%).

Conclusions:
For patients undergoing IA therapy for AIS based on CT perfusion imaging, interventions lasting greater than one hour are not associated with a higher intra-procedural complication rate, but are associated with a lower likelihood of achieving a TICI IIB or greater and an mRS </= 2 at ninety days compared to recanalizations occurring in less than one hour.
Abstract WP277: Aggressive Blood Pressure Management: A Perceived Contraindication to IV-tPA
Authors: Sands Kara A , Boehme Amelia K , Albright Karen C , Lyerly Michael J , Rawal Pawan V , Kapoor Niren , Houston James T , Alvi Muhammad , Shahripour Reza Bavarsad , Sisson April , Alexandrov Anne W , Alexandrov Andrei V
Published: March 2022

Background:
Our recent poll of US Primary Stroke Centers demonstrated that 23% of practitioners perceived the need for blood pressure (BP) management by means of a continuous dihydropyridine calcium channel blocker infusion (i.e. nicardipine) as a contraindication to IV-tPA. While the NINDS study originally excluded patients who required "aggressive" BP management, the Activase® label is silent on this criterion. In view of this persistent belief, we sought to examine the safety of IV tPA administered with nicardipine.

Methods:
A retrospective cohort study was performed over a period of 36 months examining consecutive patients treated with IV-tPA at our comprehensive stroke center who received nicardipine vs. intermittent IV labetalol or those requiring no BP medications. Patient demographics, past medical history, and stroke severity were compared. Safety was assessed by (1) symptomatic intracerebral hemorrhage (sICH) within 36 hours, defined as parenchymal hemorrhage in combination with ≥ 4 points increase in NIHSS, and (2) the presence of any hemorrhagic transformation (HT) on repeat CT or MRI.

Results:
A total of 212 patients were treated with IV-tPA, median age 68 (range 24-99), median pre-tPA bolus NIHSS 8 (range 0-32) with no differences between nicardipine treated (n=32, 15%) vs. others (n=180). Patients treated with nicardipine were more frequently female (63%; p=0.0337). Past medical history was similar except for CHF (nicardipine 0, other 15%, p=0.0087) and previous stroke (nicardipine 59%, other 36%, p=0.0132). Despite these imbalances, nicardipine patients vs. others had similar rates of sICH (0 vs. 3.3%; p=NS), or any HT (3.1% vs. 9.5%; p=NS). No telephone-assisted tPA drip-n-ship patients (n=96) received nicardipine prior to or during tPA infusion due to non-formulary status at transferring hospitals; sICH rate in this group was 4% vs. 2% (p=NS) in non-transfers with or without nicardipine.

Conclusions:
IV thrombolysis in patients requiring continuous nicardipine infusion is safe compared to those requiring less intensive BP management. The need for continuous nicardipine infusion should not be construed as rationale for withholding IV tPA in acute ischemic stroke patients.
Abstract WP281: Post-tPA Care for Acute Stroke Patients; Comparison between Intensive Care Unit Admission and Stroke Unit Admission.
Authors: Chalela Julio , Steffen Cynthia , Gay Sarah , Ramos Leah , Hays Angela
Published: March 2022

Backgound:
The American Stroke Association guidelines for acute stroke indicate that patients receiving tPA can be admitted to an ICU or a stroke unit (SU). Admission to a SU could result in cost savings and better resource allocation. We sought to compare a strategy of admitting all tPA-treated stroke patients to the ICU vs. admitting them to a SU.

Material and Methods:
Retrospective observational study. During the initial 3 years of the study all tPA patients were admitted to the ICU as we lacked a SU. In the following 2 years, patients were admitted to a new SU. We obtained baseline demographics, past medical history, admission NIHSS, treatment interventions, neurologic and medical complications, and mortality for both groups to determine if ICU admission resulted in better outcome and less complications than SU admission. Fishers exact test was used for categorical variables and proportion of the means test (t-test) for continuous variables.

Results:
A total of 71 patients were admitted to the ICU and 104 were admitted to the SU. ICU admission included 54% males and SU admission included 59% males (NS). The median age for ICU and SU admission was 69 and 70 respectively (NS). The admission NIHSS was 11 for ICU patients and 9 for SU patients (NS). The median length of stay in the ICU was 1 day (as per protocol) and the median SU length of stay was 4 days. Intravenous hypertensives (bolus) were used in 30% of ICU patients and in 18% of SU patients (p= 0.09) and continuous infusions were required in 11% of ICU patients and 6% of SU patients (p=0.04). Initial NIHSS scale of > 15 predicted need for mechanical ventilation and ICU admission (p=0.002). Intracranial hemorrhage occurred in 3% of ICU and 3% of SU patients (NS). There was no difference in medical complications (pneumonia, venous thromboembolism, sepsis, or death) in the 2 groups. There was no significant difference in the proportion of patients with excellent outcome (mRS of 1 or less) in the two groups (38% vs 36%). Stroke unit admission saves $70,000 per 100 patients per day.

Conclusions:
Stroke patients receiving intravenous tPA can be safely admitted to a SU resulting in significant savings. Patients with NIHSS > 15 are likely to need ICU admission for mechanical ventilation.
Abstract WP299: PGE2 EP1 Receptor Blockade Prevents Hemin-Induced Neurotoxicity In An In Vitro Model of Intracerebral Hemorrhage
Authors: Mohan Shekher , Narumiya Shuh , Dore Sylvain
Published: March 2022

Background:
Intracerebral hemorrhagic (ICH) stroke is defined by the rupture of intracranial artery that leads to the formation of an hematoma. Subsequently, neuronal damage is associated with the lysis of red blood cells which release hemoglobin. Hemoglobin breakdown product is the prooxidant toxic hemin. We and others have documented the various toxic or protective actions of the prostaglandin receptors in ischemic stroke. In this study, we aim to investigate the PGE2 EP1 G-protein coupled receptor’s contribution to hemin-induced neurotoxicity as an in vitro ICH model.

Methods:
Postnatal primary neuronal cultures were used to investigate hemin-induced neurotoxicity and the PGE2 EP1 receptor role. WT and EP1
-/-
neurons were treated with vehicle and hemin (12.5-100uM) for 18h and cell viability measured using LDH and calceinAM/EthD-1 assays.

Results:
Hemin increased neuronal cytotoxicity when treated with 50 (25.0±2.2), 75 (34.7±4.5) and 100uM (50.1±4.2) compared to vehicle (16.5±1.5) measured using LDH assay. Hemin at 25 (75.1±9.4), 50 (61.5±2.8), 75 (52.0±4.7) and 100uM (38.0±8.9) decreased calceinAM positive neurons compared to vehicle (96.8±4.8). Hemin also increased EthD-1 positive neurons compared to vehicle. Compared to WT neurons, hemin exposure at only 75 (28.3±5.1) and 100uM (44.3±0.8) showed significant cytotoxicity in EP1
-/-
neurons and had no significant difference in the amount of calceinAM positive neurons compared to vehicle. To further address the mechanism responsible for EP1 receptor mediated hemin-neurotoxicity, calcium-imaging experiments were conducted. Preliminary data using Fluo-8AM show significantly decreased average fluorescence intensity in EP1
-/-
neurons (3,248±435) compared to WT neurons (6,735±1,234) when treated with 1uM PGE2.

Conclusions:
Together, the results suggest that the EP1 receptor, likely through its regulation of calcium signaling, appears to aggravate the hemin-induced neurotoxicity. Ongoing experiments include detailed investigation of the regulation and the source of calcium in neurons. We also aim to determine if the EP1 receptor or the other PGE2 receptors would be unique therapeutic target(s) against hemolysis induced by various ICH preclinical models.
Abstract WP306: Determinants of Hematoma Volume Differ by Location in Intracerebral Hemorrhage
Authors: Falcone Guido J , Biffi Alessandro , Brouwers H. B , Anderson Christopher , Battey Thomas W , Ayres Alison M , Vashkevich Anastasia , Schwab Kristin , Rost Natalia S , Goldstein Joshua N , Viswanathan Anand , Greenberg Steven M , Rosand Jonathan
Published: March 2022

Background and purpose:
Admission hematoma volume (AHV) is the strongest predictor of outcome in intracerebral hemorrhage (ICH). Mounting evidence suggests that the biological mechanisms underlying ICH occurrence differ by bleeding location. We aimed to assess if the determinants of AHV vary by bleeding topography, and to estimate location-specific effects for warfarin, a factor known to influence AHV.

Methods:
Retrospective analysis of 902 ICH cases (388 deep, 356 lobar and 58 cerebellar) enrolled in a single-center, prospective study of ICH. AHV was measured in the first available computed tomography using semi-automated, computer-assisted volumetric methods. Univariate and multivariate linear regression analyses, stratified by ICH location, were implemented to model natural log-transformed AHV as a function of covariates. Admission International Normalized Ratio (INR) values were utilized to establish intensity of anticoagulation. INR was categorized in <1.2, 1.2-2, 2.1-3 and >3.

Results:
AHV medians (interquartile range) for deep, lobar and cerebellar ICH were 13 (35), 39 (59) and 13 (24), respectively (p<0.0001). Within these location categories, 18, 21 and 29% of subjects were on warfarin, and 36, 42 and 35% had died at 90 days, respectively. In multivariate analysis, independent predictors of deep AHV were male sex (beta[β]=0.28, standard error[SE]=0.14, p=0.05), history of coronary artery disease (β=0.33, SE=0.17, p=0.05), and degree of anticoagulation (β=0.32, SE=0.08, p=0.00005, tested for trend across INR categories); predictors of lobar AHV were antiplatelet treatment (β=0.27, SE=0.13, p=0.03) and degree of anticoagulation (β=0.14, SE=0.06, p=0.02, comparing INR <1.2 to >3); and predictors of cerebellar AHV were effective anticoagulation (β=0.99, SE=0.41, p=0.02, comparing INR <2 vs INR >2) and statin treatment (β=-1.21, SE=0.38, p=0.001).

Conclusion:
Determinants of AHV differ by ICH location. Anticoagulation is associated with larger AHV in all locations, but the strength and shape of the dose-response curve for this relationship varies with ICH topography. Pre-ICH treatment with antiplatelets and statins was associated with increased mean lobar AHV and decreased mean cerebellar AHV, respectively.
Abstract WP307: Administration of Tissue Plasminogen Activator to Patients with Spontaneous ICH Does Not Lead to an Increase in Perihematomal Edema
Authors: Mould W. Andrew , Carhuapoma J. Ricardo , Muschelli John , Hanley Daniel F ,   and the MISTIE Investigators
Published: March 2022

INTRODUCTION:
In patients with spontaneous intracerebral hemorrhage (ICH), blood toxicity leading to perihematomal edema (PHE) is a major concern. Some observations suggest the possibility that administering tissue plasminogen activator (tPA) increases neurotoxicity and therefore PHE. With reports linking PHE to clinical deterioration and death in hemorrhagic stroke patients, it is important to further investigate any relation between PHE and tPA. We hypothesized that treatment with tPA would show increased levels of edema when compared to surgical aspiration alone.

Methods:
Minimally Invasive Surgery plus Tissue Plasminogen Activator for Intracerebral Hemorrhage Evacuation (MISTIE) is a multi-center, prospective, randomized trial testing the safety and efficacy of hematoma evacuation after spontaneous ICH compared to medical management. Study interventions were consistently applied in a protocol-based manner across all study sites. We conducted a semi-automated, computerized volumetric analysis on CT imaging to assess the effect of tPA toxicity on PHE. CT scans were assessed for ICH and PHE volumes at two time points: T1, pre-enrollment, and T2, end of treatment.

Results:
Out of 123 patients enrolled, 79 patients in the surgical arm were treated in two respects, 69 received surgical aspiration followed by administration of tPA (S+tPA), and 10 received surgical aspiration only (SO). There was no significant difference between the treatment groups in enrollment GCS, intraventricular involvement, time from symptom onset to T1 or T2, baseline ICH volume, or baseline PHE volume. A slight age difference was seen between the two groups: SO, 68.90±9.2; and S+tPA, 59.43±11.4 (p-value=0.01). Both treatment cohorts achieved similar blood clot reduction: S+tPA, 18.94±14.5 cc; and SO, 24.51±14.0 cc (p-value= 0.26). The mean amount of edema at T2 in patients treated with S+tPA was 28.15±13.8 cc while patients treated with SO was 24.38 ±8.6 cc, showing no exacerbation of edema in either group (p-value=0.41).

Conclusion:
These findings demonstrate perihematomal edema is not altered by tPA, making neurotoxicity of tPA unlikely when the drug is delivered to intracranial clot.
Abstract WP311: Estimating Supported Outcomes in Intracerebral Hemorrhage Patients with Withdrawal of Life Support through Propensity Score Matching
Authors: Tirschwell David L , Chang Yuchiao , Ayres Alison M , Schwab Kristin , Dipucchio Zora , Vashkevich Anastasia , Viswanathan Anand , Greenberg Steven M , Goldstein Joshua N , Rosand Jonathan
Published: March 2022

Background:
Observational reports have suggested that a self-fulfilling prognostic pessimism may lead to withdrawal of life support (WOLS) in more severe intracerebral hemorrhage patients (ICHs) who might otherwise have acceptable clinical outcomes. Our objective was to estimate outcomes in a cohort of ICHs who had WOLS, if instead they had life support continued.

Methods:
Multivariable modeling was used to create a propensity score (PS) for WOLS in a Boston single center cohort of ICHs with follow up modified Rankin Scale (mRS) or known death at 6 months. Individual ICHs with WOLS were then matched to individual ICHs without WOLS and baseline variables and outcomes compared.

Results:
There were 576 ICHs with all variables available for analysis; mean age was 72 years, 44% women, 83% white and WOLS in 45%. Factors used to create the PS for WOLS included age, GCS, ICH and IVH volume, diabetes, ICH location, SBP, sex, race, history of HTN, DM, CAD, atrial fibrillation, warfarin, intubation, and EVD. WOLS/non-WOLS matches were possible for 81 pairs (N=162 total), and the groups were well matched on all PS variables; key values included mean age (73 years), GCS (9.5), ICH volume (37cc) and % intubation (57) and EVD use (23); more patients had dementia in the WOLS group than non-WOLS (24 vs. 11%, p=0.03). Follow up mRS in the WOLS group was 3 in 1.2%, 5 in 2.5% and 6 (death) in 96%; in the matched non-WOLS group, % in mRS scores 0-6 were 4.9, 8.6, 3.7, 24.7, 25.9, 16.0 and 16.0 respectively (p<0.0001 for difference in distribution). Using mRS <= 3 as an acceptable outcome, % in WOLS/non-WOLS were 1.2%/42% (difference p<0.0001).

Conclusions:
The proportion of ICHs with WOLS that, without WOLS, might have had an acceptable clinical outcome was estimated to be 42%, suggesting that for every 2-3 less ICHs with WOLS, one more patient might have an acceptable clinical outcome. This proportion might vary depending on an individual patient’s interpretation of what constitutes an acceptable outcome.
Abstract WP316: Submaximal Exercise Test to Predict VO2 Peak in Subacute Stroke
Authors: Billinger Sandra A , Mattlage Anna E , Lentz Angela A , Rippee Michael A
Published: March 2022

Purpose:
Submaximal exercise testing can be an attractive alternative to peak testing especially in clinical environments where a metabolic cart and adequately trained medical staff may not be readily available. We examined the relationship between peak oxygen consumption (VO2 peak) and a predicted VO2 peak value obtained from a submaximal exercise test that we developed for a total body recumbent stepper (TBRS). We hypothesized that in people with subacute stroke, the actual VO2 peak and predicted VO2 peak would have a moderate (r > 0.75) relationship.

Methods:
Ten individuals in the subacute stage of stroke recovery (68.6+40.1 days post-stroke) and 61.2+ 5.0 years of age participated in the study. Exercise testing using a metabolic cart and the TBRS for the exercise modality was performed on the first day to obtain VO2 peak. We used the Young Men’s Christian Association (YMCA) protocol for the TBRS. The step rate was maintained between 95-100 steps per minute (spm). Participants started the test at 30 watts and resistance was increased every 3 minutes according to the protocol until volitional fatigue, or 85% of age-predicted HR max was achieved. HR was recorded ten seconds prior to the end of the second and third minute of each stage. If the two HR measures were within 5 bpm of each other, participants progressed to the next stage. However, if the difference was greater than 5 bpm, an additional minute was performed to ensure a steady-state. The participants completed the submaximal exercise test within one to two days after the peak exercise test. The workload in watts and HR at the end of the submaximal exercise test along with age, sex and weight (kg) were used in the equation to predict VO2 peak.

Results:
We found that predicted VO2 peak generated from the submaximal exercise test equation had a strong correlation to the actual VO2 peak (r = 0.80, p = 0.006). Mean peakVO2 (ml*kg-1*min-1) from the exercise test was 22.9 + 7.3 ml*kg-1*min-1 and the predicted mean value was 17.6 + 6.1 ml*kg-1*min-1. Paired t-test revealed a statistically significant difference between these two values (p = 0.005).

Conclusion:
This preliminary data demonstrates the TBRS submaximal exercise test shows promise for assessing VO2 peak in sub-acute stroke.
Abstract WP318: Level And Predictors Of Participation In Stroke Patients Undergoing Inpatient Rehabilitation
Authors: Kong Keng , Yang Su Y
Published: March 2022

Background:
The level of participation is an important factor influencing rehabilitation outcome. However, few studies have evaluated rehabilitation participation and its clinical predictors. The objectives of this study were to establish the level of participation in a cohort of stroke patients undergoing inpatient rehabilitation and define its clinical predictors.

Methods:
This was a prospective observational study of a cohort of first-ever stroke patients admitted to a rehabilitation centre over a 12-month period. The primary outcome measure was the level of rehabilitation participation as measured on the Pittsburgh Rehabilitation Participation Scale (PRPS). The PRPS was measured 1 week after admission to and 1 week before planned discharge from inpatient rehabilitation. Other outcome measures evaluated included National Institute of Health Stroke Scale (NIHSS), Functional Independence Measure (FIM), Elderly Cognitive Assessment Questionnaire (ECAQ), Centre for Epidemiologic Studies -Depression Scale (CES-D), Fatigue Severity Scale (FSS), Lubben Social Network Scale-Revised (LSNS-R) and health attitudes and beliefs.

Results:
A total of 122 stroke patients were studied. The mean PRPS score on admission was relatively high at 4.36(0.9) on admission and this improved to 4.65(0.79) on before planned discharge.(p<0.001). On multivariate analysis, the mean PRPS score on admission was predicted by admission FIM, EACQ and FSS scores but not by age, gender, depression, social support or health attitudes and beliefs.

Conclusions:
Patients with lower levels of participation were more likely to be functionally dependent, cognitively impaired and have more fatigue. We suggest that apart from cognition, fatigue should be routinely screened in stroke patients undergoing rehabilitation.
Abstract WP319: Can Acupuncture Benefit Putaminal Hemorrhagic Stroke Patients? A Randomized Controlled Clinical Trial.
Authors: Wong George K ,   CUHK-Shatin Hosp Neurosurgical Rsch (Acupuncture) Group
Published: March 2022

Background:
Acupuncture is a low-risk treatment with purported claims of effectiveness for poststroke rehabilitation. Poor study quality hinders the strength of previous studies to support acupuncture as a routine clinical practice. Moreover, most of the reported studies focus on ischemic stroke patients. In daily neurosurgical encounter, putaminal hemorrhagic stroke patients have a significantly worse functional and neurological prognosis than ischemic stroke patients.

Hypothesis:
We hypothesize that acupuncture can improve functional outcome of putaminal hemorrhagic stroke patients by improving the neurological outcome.

Study design:
Randomized controlled clinical trial (ClinicalTrial.gov:
NCT01037894
).

Study population:
Putaminal hemorrhagic stroke patients who are hemiplegic and can cooperate with acupuncture treatment.

Study intervention:
Acupuncture treatment for six weeks versus placebo. All patients received intensive inpatient rehabilitation.

Study outcome:
Functional (primary) outcome is measured by Functional Independent Measure (FIM); Neurological (secondary) outcomes include by Fugl-Meyers Scale (FMS), Modified Functional Ambulation Category (MFAC), Modified Rivermead Mobility Index (MRMI), Glasgow Outcome Scale Extended (GOSE), Neurocognitive State Examination (NCSE), and Short Form-36.

Results:
Twenty-nine eligible patients were randomized and completed all assessments. Acupuncture and placebo groups have similar baseline FIM scores (p=0.337). At both weeks 3 and 6 assessments, the FIM scores are significantly higher among acupuncture group (week 3: 51+/-19 vs 68+/-20, p=0.027; week 6: 59+/-20 vs 80+/-23, p=0.017). There is also significant improvement of FMS of lower limbs at week 6 but not upper limbs.

Conclusions:
Acupuncture, in addition to intensive inpatient rehabilitation, improves functional and neurological outcomes of putaminal hemorrhagic stroke patients. Rehabilitation of the upper limb function remained a challenge for putaminal hemorrhagic stroke patients.
Abstract WP327: Strategies for Improving Stroke Caregiver Readiness
Authors: Lutz Barbara J , Young Mary Ellen , Martz Crystal , Creasy Kerry Rae
Published: March 2022

Introduction:
Stroke occurs suddenly causing significant residual impairment for stroke survivors requiring long-term assistance by family caregivers. Becoming a caregiver can be an overwhelming, difficult process and stroke caregivers often experience poorer health and higher mortality rates than non-caregivers.

Methods:
In this grounded theory study, we explored stroke caregivers’ needs and assessed their capacity and readiness to assume the caregiving role as the stroke survivor transitioned home from inpatient rehabilitation. Our sample included a comparison group (9 patient/family units) and an intervention group (10 patient/family units) for a total of 19 stroke survivors and 22 family caregivers. Participants were interviewed during inpatient rehabilitation, and at 1 and 3 months post-discharge. In the first interview, comparison group questions focused on understanding family members’ perceptions about how prepared they were to assume the caregiving role. In the intervention group we conducted 1 hour interviews to assess specific domains of caregiver capacity and readiness to assume the role and reported the findings to the stroke rehabilitation team prior to discharge. In the 2 post-discharge interviews in both groups, we explored caregivers’ perceptions about how prepared they were to manage the stroke survivors’ post-discharge needs. Interviews were analyzed using dimensional analysis and coded in NVivo data management software.

Findings:
Family members in both groups indicated they were not “ready” to assume the caregiving role and there was not enough time for them to prepare pre-discharge. Dimensions of readiness included having the commitment, resources, and ability to sustain the role. Pre-existing conditions, such as physical and mental health concerns, other roles/responsibilities, and home inaccessibility limited their caregiving capacity.

Conclusions:
In order to adequately prepare family caregivers, we must assess their caregiving capacity pre-discharge and develop plans to address gaps so that they will be ready to assume the role long-term. Rehabilitation lengths of stay are often insufficient to address these gaps requiring interventions to help caregivers bridge the gap as they transition home.
Abstract WP331: Diverse Microglia Morphologies Induced By Ischemic Stroke And Reperfusion Are Not Accompanied By Altered Brain Inducible Nitric Oxide Synthase Expression.
Authors: Morrison Helena W , Filosa Jessica A
Published: March 2022

Microglia cells continuously survey the healthy brain in a ramified morphology and, in response to injury, undergo progressive morphological and functional changes that encompass microglia activation. Activated microglia may contribute towards secondary injury during ischemic stroke and reperfusion (ISR) through pro-inflammatory mechanisms and increased oxidative stress. Nitric oxide (NO), a product of microglia inducible NO synthase (iNOS) expression, contributes toward increased oxidative stress after brain injury. Although ideally positioned for an immediate response, microglia morphological responses have not been characterized after ISR. In addition it is not well understood if microglia morphology correlate to microglia function relative to oxidative stress. Our aim was to quantify microglia morphology and iNOS expression, an indicator of NO production, during the evolution of cerebral injury after ISR. Anesthetized mice were subjected to focal ischemic stroke accompanied by varied lengths of reperfusion (ischemia only, 8hr and 24hr reperfusion). Microglia process length/cell and number of endpoints/cell was quantified from immunofluorescent confocal images of brain regions spatially related to the necrotic core using a skeleton analysis method developed for this study. Live cell microglia morphology and process movement was measured from movies acquired in acute brain slices from GFP-CX3CR1 transgenic mice after IS and 24hr reperfusion. iNOS expression was measured at all time-points and similar brain regions using western blot techniques. We show a significant spatiotemporal relationship between microglia process length/cell and number of process endpoints/cell and evolving brain lesion after ISR (F=4.17, p<0.001, F=3.57, p<0.01). After 24hr of reperfusion, process activity was significantly decreased the peri-infarct region vs. contralateral (p<0.05). However, iNOS protein expression remained unchanged in all ipsilateral regions vs. matching contralateral regions after 60min ischemia and first 24hr of reperfusion. While microglia morphological responses to ISR are immediate and diverse, we have yet to confirm microglial sources of NO are increased within the first 24hr of ISR.
Abstract WP347: Telestroke Practice With Integrated Quality Improvement Strategy Increases Use of IV tPA in Rural Minnesota.
Authors: Castle Amy , Buckentin Karen , Massman Patty , Anderson Louise , Pasche Jeanette , Wurtzberger Terry
Published: March 2022

Background:
In Minnesota, stroke is the cause of 2000 deaths, 12,000 hospitalizations with 1 in 3 presenting first to a rural hospital where resources for stroke care are limited. Nationally the percent of all acute ischemic stroke (AIS) patients presenting to acute care hospitals receiving IV tPA remains low with long times to treatment (4.3% and mean DTD time 79 min - GWTG data 2003-2009). This review supports the hypothesis that a stroke system utilizing telestroke with an integrated approach to the team process and quality review will increase the percentage of AIS patients treated and foster short door-to-drug times.

Methods:
The HealthEast Telestroke Network began in 2006, currently there are five hospitals within the system. During the implementation, team meetings occur with spoke hospital staff to collaboratively develop the stroke code process which includes a door to drug goal of 30 minutes. Components of this process include use of aggressive triage plan for ambulatory arrivals, partnering with EMS for pre-alerts, specific team member assignments and time goals, early stroke neurology involvement and leadership of the code. This integrated team approach continues into the quarterly quality review with cooperative hub and spoke meetings to address barriers and effect continuous improvement of the process.

Results:
Currently, our rate of all ischemic stroke discharges treated across our telestroke network hospitals is 24%. Comparisons between each of the five network hospital’s rates of all ischemic stroke treated is 17% to 34%. Mean door to drug time across the network is 58 minutes, with a range across sites of 46 to 67 minutes and sixty percent of patients receiving IV tPA within 60 minutes or less.

Conclusion:
Use of telestroke combined with an integrated approach to the team process and quality review resulted in a sustained high percentage of AIS patients treated with reperfusion therapies with door- to- drug times comparing favorably to nationally reported data.
Abstract WP349: Effectiveness of Rural Community Stroke Screenings on Identification and Physician Follow up for Stroke Risk Factors
Authors: Rankin Pauline M , Perry Christine R , McLaughlin James R
Published: March 2022

Success of community stroke screenings in increasing awareness of stroke signs and symptoms in participants is well documented. There is little evidence-based literature regarding the effectiveness of this methodology in eliciting healthcare interventions for stroke risk factors identified in individual participants. A quality assurance initiative was started in our 180 bed rural hospital serving Northwest Pennsylvania, to monitor the effectiveness of community stroke screenings. We hypothesized that stroke risk factors identified in community stroke screenings would be addressed by healthcare interventions through the primary care physician (PCP). We used a sample population of 276 participants, representing all those participating in screenings provided by our hospital during Nov.-Dec. 2011. There were 61 participants with identified stroke risk factors who were directed to contact their PCP. Of these, 56 were contacted by telephone and interviewed regarding their follow-up on the identified risk factors using a standardized script. A written release form allowing contact with their PCP regarding treatment interventions was obtained and a standardized questionnaire was mailed to the physicians. Results from the participant interviews showed that 49 (87%) recalled the stroke nurse emphasizing the importance of follow- up for the identified risk factors with their PCP, and 42 (75%) had followed up with their PCP. Treatment had been initiated or modified in 22 (52%). Of the 14 who had not followed up with their PCP, 6 (46%) indicated that the follow-up interview prompted them to make an appointment. Only 15 physician questionnaires were returned; 14 (93%) of these participants followed up for risk factors identified and 11 (79%) received treatment. In conclusion, community stroke screening and education can effectively influence care for identified risk factors, but this is dependent on participant follow-up with their PCP. Our goal is to continue offering community stroke screenings in a rural setting with limited healthcare resources and monitor participant and PCP follow- up in an effort to reduce stroke risk factors.
Abstract WP35: An ASL Collateral Score Can Identify Improved Quantitative Cerebral Blood Flow in Acute Stroke Patients
Authors: Christen Thomas , Zhao Chen , Coram Marc A , Straka Matus , Bammer Roland , Albers Gregory W , Zaharchuk Greg
Published: March 2022

Objective:
To measure quantitative hemodynamic parameters in acute stroke patients using a tomographic collateral assessment based on arterial spin labeling (ASL) [1].

Methods:
Patients were retrospectively identified who met these criteria: symptom onset <27 hrs, DWI volume >=10 ml, and ASL and bolus contrast PWI, 1.5T. Pseudocontinuous 3D fast spin echo ASL was performed with the parameters: TR/TE/label time/post-label delay 5500/9.5/1500/2000 ms. PWI was performed using 0.1 mmol Gd and single-shot EPI with the parameters: TR/TE 1800/40 ms. Automated software (RAPID) was used to measure relative CBF, CBV, and time to peak of the residue function (Tmax) [2]. The combined ASL and DSC method was used to determine quantitative CBF and CBV [3]. A four point collateral score (CS) (0=poor, 1=intermediate, 2=good, 3=antegrade perfusion) [4] was determined based on ASL arterial transit artifact (ATA) in 20 ASPECTS ROI’s in each patient [1]. Tests for significant relationships between CS and each parameter was performed.

Findings:
13 patients were identified (4 M, 63±13 yrs, 17±7 hrs from symptom onset, DWI size 61±52 ml, PWI Tmax>6 sec size 84±65 ml). CBF increased with increasing CS, with the highest CBF in the antegrade perfused regions. CBV also increased with CS, but there was no difference between good collateral and antegrade regions. Tmax decreased significantly as CS increased. Acute stroke patients with good and poor collaterals are shown in the Figure (yellow arrows = collaterals).

Conclusions:
Collaterals are important because they supply CBF. ASL is able to predict the quality of collaterals in acute stroke, as was shown previously in Moyamoya disease [1]. This non-contrast assessment of collaterals on MRI may improve patient selection for stroke therapy.

References:
1. Zaharchuk et al., Stroke 2011; 42:2485-91; 2. Straka et al., JMRI 2010; 32:1024-37; 3. Zaharchuk et al., Magn Reson Med 2010; 63:1548-56; 4. Kim et al., Stroke 2004; 35:1340-4.
Abstract WP353: Implementation of the Stroke Clinical Nurse Leader enhances patient care
Authors: Quimby Susan
Published: March 2022

Background and Issues:
Stroke patients and their caregivers require formalized education to assist in prevention and post-stroke rehabilitation for optimal outcomes.

Purpose:
The purpose of this program was to improve the quality of care delivered to our stroke population, enhance the patient experience, and advance our patients and their caregivers’ knowledge regarding strokes and prevention.

Methods:
Implementation of the Stroke Clinical Nurse Leader (CNL) enhances lateral integration of care and evidence-based care in our stroke population. The CNL manages clinical outcomes, adherence to clinical guidelines, patient satisfaction, and quality of care. The CNL serves as a mentor and impacts the care environment. The CNL coordinates and facilitates the multiple services and disciplines impacting on the patient assuring the most efficient and effective goal-directed activities are provided at the right time and in partnership with all other disciplines providing care.

Results:

Conclusions:
Implementing the role of the CNL demonstrated a reduction in length of stay and improvement in quality measures. Our patients and family members are more knowledgable and prepared to cope with their new diagnosis as well as preventative measures for stroke reccurence.