bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP472: A Model of the Code Stroke Process for Rural Community Hospitals that Utilizes a Critical Care Nurse to Decrease Door-to-Needle Times and Improve Patient Outcomes
Authors: Talley Joshua , Hood Samuel J , Oden Matt , Sharma Jitendra
Published: January 2019

Background and Purpose:
In this 600 bed, non-academic community hospital, door-to-needle times soared to as high as 120 minutes in some cases. Issues ranged from high acuity patients in the Emergency Department to RN’s not knowing how to mix and give tPA. The stroke neurologist and ED physicians desired to come up with a protocol that would better serve this population of patients.

Methods:
A Stroke Team was established, led by the Stroke Neurologist. The team designed a Code Stroke Protocol and determined that the protocol should be led by a critical care nurse from the SICU. They would be intensely trained on the stroke protocol and would respond to all code strokes. In addition, a “code stroke backpack” was created that carries everything the nurse could need to administer tPA. The backpack includes the tPA and a nicardipine drip, among other medications that could be used during the code stroke. Having a strict protocol, a trained critical care nurse, and the medicine in a backpack, would streamline the process.

Results:
After initiating the new code stroke process, there was a significant decrease in door-to-needle times [78.9 min average (January 2016-February 2017)] to [36.8 min average (March 2017-December 2017)]. There was an immediate 36 minute drop the month of initiation. NIH scores have shown dramatic decreases in post tPA patients.

Conclusions:
In conclusion, the use of a critical care nurse to run the code stroke, proved to be highly successful and more importantly, sustainable. With a core of nurses that are proficient at the code stroke protocol, pressure was taken off of the emergency department nurses and limited issues that would prolong the administration of tPA. This process is differentiated from others by the stroke-trained nurse carrying the backpack with the medications. It should be considered in rural community hospitals with less resources than larger medical centers.
Abstract TP481: Rapid Improvement of Malnutrition Following Treatment by Leucine- Enhanced Branched Chain Amino Acid in Severe Acute Stroke Patients Fed With Enteral Nutrition
Authors: Oonuma Yuko , Tanno Yuhei , Chiba Nozomi , Mori Takahisa
Published: January 2019

Background and Issues:
Malnutrition such as hypo-proteinemia or sarcopenia often occurs in severe acute stroke patients fed with enteral nutrition. However, it has not been established how to Improve the malnutrition. Leucine, one of essential branched chain amino acids (BCAA), has been shown to trigger muscle growth or stimulate muscle protein synthesis.

Purpose:
Leucine-enhanced BCAA (LE-BCAA) supplementations can stimulate protein synthesis and improve hypo-proteinemia in severe acute stroke patients.

Methods:
We included acute stroke patients 1) who were admitted from October 2016 to July 2018, 2) who received enteral nutrition due to severe stroke while their hospitalization 3) whose serum Pre-albumin (Pre-Alb) levels dropped below 20 mg/dl during hospitalization 4) who received LE-BCAA supplementation including leucine more than 1.2 g of leucine per 200 kcal. We measured Biochemical indices for nutrition assessment (Albumin (Alb), Pre-Alb, and Total Cholesterol (T-CHO)) just before and 3 days after starting LE-BCAA.

Results:
Fifty-six patients met our inclusive criteria and female gender was 35. Their average age was 85 years. Their average body mass index (BMI) on admission was 19.9 kg/m2. When LE-BCAA was started median on the 4
th
day after admission, patients’ median Pre-Alb was 12.4 mg/dl, indication severe malnutrition. Then, patients started to tale more than 2.8 g per day of Leucine by LE-BCAA and 3 days later their median Pre-Alb increased up to 13.8 mg/dl, although median Alb level decreased from 2.9 to 2.6 g/dl and median T-CHO level decreased from 164 to 156 mg/dl just before and 3 days after LE-BCAA. Among 56 patients, 41 (73%) had decrease of serum albumin level, 32 (58%) had decrease of serum T-CHO level, whereas 37 (66%) experienced rapid increase of serum Pre-Alb level, this was probably because Pre-Alb was one of rapid turnover proteins.

Conclusions:
Leucine-enhanced BCAA supplementation can stimulate protein synthesis and achieve rapid improvement of hypoproteinemia in severe stroke patients fed with enteral nutrition.
Abstract TP487: Data Dashboard: Making the Electronic Medical Record Work for You
Authors: Conahan Erin , Mathiesen Claranne
Published: January 2019

Background:
Stroke care is becoming increasingly complex in the 21st century. In order to assure optimal patient outcomes, our health network developed a stroke care pathway based on evidence-based practices and expert consensus. Overall goals for the project include increased adherence to practice standards and defined process metrics. This project is part of a larger institutional initiative for specific disease states. An integral aspect of the project was the development and implementation of a dashboard allowing for a global view of the stroke population as well as the ability to drill down to the patient or provider level.

Purpose:
The purpose of the dashboard is to use data to evaluate trends and develop data driven interventions. This tool is available to key stakeholders including administration, quality, program leadership and care providers.

Methods:
The pathway initiative is a collaboration between quality, clinical, and data analytic teams. It used a multidisciplinary approach and included input from services throughout the care continuum. Clinical pathways for stroke alert, reperfusion, neurointerventional care, and nursing care were developed and recently launched. The dashboard auto-populates from discreet fields within the electronic medical record. It is an informational tool that allows for data transparency through the use of interactive charts and graphs which provides temporal trending.

Results:
Utilization of this approach supports system level data trending and analysis. Preliminary results demonstrate improved provider engagement, reduction in variability in several care processes, and data transparency through accessible real-time reporting.

Conclusions:
Disease specific dashboards using automatic data feeds from the electronic medical record allow for evaluation of program efficiencies, population trends, and provider level data without additional manual abstraction or analysis. Evaluating data in real time allows for identification of variations in practice, real-time interventions targeting identified variances, as well as determining the effectiveness of interventions on quality and cost of care.
Abstract TP488: Comparison Reveals Decrease Door to Needle Times and Increase IV Alteplase Utilization
Authors: Duke Kimberley , Hartman Richelle , Holland Donna , Liable Deborah , Roth Jeffrey , Smith Crystal , Smith Evelyn , Wikas Angie
Published: January 2019

Background and Purpose:
The Banner Health system includes 8 stroke-certified hospitals; 1 Comprehensive Stroke Center (CSC) and 7 Primary Stroke Centers (PSC). Each CSC/PSC employs a minimum of one Stroke Coordinator who oversees the program, monitors data and ensures compliance with Joint Commission standards. Since October 2012, the Stroke Coordinators have worked together focusing on standardization of the stroke process across the Banner Health system. The purpose of this process improvement initiative was to determine the effectiveness of collaboration, sharing of common barriers and best practices, measured by average door-to-needle times and utilization of IV alteplase.

Methods:
IV alteplase utilization was calculated using discharge coded acute ischemic stroke patients; the average door to needle time was calculated utilizing the defined inclusion criteria from Get with the Guidelines. Current outcomes were compared to those from the prior process improvement initiative from January 2012 to December 2014. To maintain the integrity of the data, one of the 8 Banner Health stroke certified hospitals did not participate in the data collection process and as they were not acquired until after 2015.

Results:
In comparison to the data collected from the initiative from 2012-2014, the 2015-2017 average door to needle times decreased by 32%. Concurrently, there was 51.4% increase in IV alteplase utilization.

Conclusion:
Collaboration and standardization of stroke care across the Banner Health system resulted in a decrease in average door to needle times and an increase in utilization of IV alteplase from 2012-2017. Continual assessment of average door to needle times and utilization of IV alteplase will assist in supporting best practices across all Banner Health stroke centers, in addition to possible implications on lowering Endovascular Door-in, Door-out times.
Abstract TP496: Placental Ischemia Exposure Leads to Increased Cerebral Microbleeds in Embryonic Day 19 Rat Offspring
Authors: Giambrone Ashtin B , Logue Omar C , Shao Qingmei , Bidwell Gene L , Warrington Junie P
Published: January 2019

Perinatal stroke (cerebrovascular injury) affects more than 1 in 3000 live births and is associated with preeclampsia and low placental perfusion. Previous studies have shown that placental ischemia in the rat, induced by surgical reduction of uterine perfusion pressure (RUPP), leads to increased circulating pro-inflammatory cytokines, similar to preeclampsia patients. While there is a strong link between perinatal stroke and low placental perfusion, it is not known whether pups exposed to placental ischemia develop cerebral microbleeds and neuroinflammation
in utero
. Thus, this study assessed whether placental ischemia induces microbleeds and a pro-inflammatory environment in brains of embryonic day (E)19 offspring. Sham or RUPP surgery was performed on timed-pregnant Sprague Dawley rats (260g) on gestational day 14, and pup brains extracted on E19. Compared to sham, RUPP-exposed pups had increased number of microbleeds (H&E stain: 2.1±0.4 vs. 0.9±0.2; p=0.007) at E19, indicative of structural microvascular abnormalities in the developing fetal brain. Using a multi-plex cytokine/chemokine kit, E19 rat pups exposed to placental ischemia (n=5 pup brains/group), had higher levels of 7 out of 27 cytokines/chemokines: Eotaxin (5.76±0.26 vs. 3.86±0.84 pg/mg protein; p=0.03), Interleukin (IL)-1β (5.17±0.25 vs. 3.70±0.43 pg/mg; p=0.01), IL-6 (72±10.5 vs. 46.3±7.01 pg/mg; p=0.04), LIX (CXCL5; 45.8±2.2 vs. 30.4±4.7; p=0.01), IL-17 (1.12±0.51 vs. 0.27±0.03; p=0.02), IL-18 (330.1±40.9 vs. 226.5±18.3; p=0.02), and macrophage inflammatory protein 2 (20.8±0.5 vs. 15.7±1.9 pg/mg; p=0.02). The number of microbleeds was positively correlated with cerebral IL-6 levels (p=0.03). Thus, our data support the use of the RUPP model as a tool for assessing underlying mechanisms for perinatal stroke in patients with low placental perfusion or preeclampsia. Future studies will assess the role of IL-6 in mediating increased microbleeds in RUPP offspring.
Abstract TP51: Rescue Tirofiban During Mechanical Thrombectomy for Acute Ischemic Stroke Patients With Bridging Intravenous Thrombolysis
Authors: Huo Xiaochuan , Yang Ming , Gao Feng , Wang Anxin , Zhang Xiaoli , Ma Ning , Mo Dapeng , Wang Yongjun , Miao Zhongrong
Published: January 2019

Background and Purpose:
Whether rescue tirofiban is safe and effective for acute ischemic stroke(AIS) patients undergoing mechanical thrombectomy (MT) with bridging intravenous thrombolysis (IVT) remains unclear. We aim to evaluate the safetyand efficacy of rescue tirofiban during MT in AIS patients treated with bridging IVT.

Methods:
We derived data from the ANGEL study, a multi-centric, prospective registry study that included MT patients owing to proximal large-artery occlusionfrom June 2015 to December 2017. Patients with bridging IVT were enrolled in the current study and were dichotomized into tirofiban and non-tirofiban group according to whether rescue tirofiban was performed during and after MT. Safety (symptomatic intracerebral hemorrhage [sICH] ICH and thrombus distalization) and efficacy outcomes (artery recanalization and functional outcomes at 3-month follow-up) were compared between groups.

Results:
We included 207 patientsfrom the entire 917 patients in the Registry. Among them, there were 55 in tirofiban group and 152 in non-tirofiban group, and 17 (8.2%) patients suffered sICH; 36 (17.4%) suffered ICH within 24 hours post-MT; 11 (5.3%) experienced thrombus distalization; 111 (53.6%) achieved functional independence and 34 (16.4%) died after three-month follow-up. No significant differences of safety outcomes on sICH, ICH and thrombus distalization and efficacy outcomes on artery recanalization and long-term functional independence were found between tirofiban and non-tirofiban group(p>0.05 for all groups). Yet, rescue tirofiban was significantly correlated with long-term mortality reduction for patients underwent MT with bridging IVT (adjusted hazard ratio 0.28 [0.08-0.94], adjusted p=0.03).

Conclusion:
In AIS patients underwent MT with bridging IVT, rescue tirofiban was not correlated with increased risk of safety outcomes on sICH, ICH or thrombus distalization and was associated with lower risk of long-term mortality
Abstract TP512: White Matter Lesion Volume Change and Antiplatelet Treatment in Small Vessel Disease; Quantitative Analysis From Picasso Study
Authors: Kim Bum Joon , Kwon Sun U , Kim Yong-Hwan , Kang Dong-Wha
Published: January 2019

Background:
White matter lesion (WML) is associated with future stroke risk and cognitive decline. Though antiplatelet treatment strategy is important in the prevention of secondary stroke, the effect on WML volume change is not clarified yet.

Methods:
This study was performed by a post-hoc analysis of PICASSO study which compared the efficacy and safety of cilostazol versus aspirin in patients with small vessel disease. Among those who have a follow-up imaging data, change of WML volume was measured quantitatively and automatically. Segmented lesion maps of different time points were compared using the longitudinal pipeline. The absolute difference was compared between aspirin and cilostazol. Factors associated with the change of WML volume were analyzed.

Result:
Among those enrolled in PICASSO trial, 505 patients (254 in aspirin group and 251 in cilostazol group) was measured. WML volume decreased 0.5±11.6cc at follow-up. There was no difference in WML change between cilostazol and aspirin (-0.7±12.5cc vs. -0.2±10.6; p=0.60). Old age (r=0.12, p=0.006), diabetes (p=0.03) and longer follow-up period (r=0.11; p=0.012) was associated with increase of WML. Interestingly, the presence of diabetes was associated with increased WML in aspirin group (2.4±10.3cc vs. -1.5±10.6cc; p=0.006), but not in cilostazol group (-0.3±15.0cc vs, -0.9±11.4cc; p=0.7; p for interaction=0.15). Furthermore, WML increased in aspirin group significantly with low initial systolic blood pressure (r=0.20, p=0.02), but not in cilostazol group (p=0.75; p for interaction=0.01).

Conclusion:
Though there is no significant difference in WML change between cilostazol and aspirin treatment, factors associated with WML change may differ according to antiplatelet treatment.
Abstract TP521: Changes in D-Dimer Levels With Heparin Treatment Indicate the Recurrent Stroke Risk in Patients With Cancer Associated Hypercoagulation
Authors: Fujinami Jun , Makita Naoki , Maezono Keiko , Ogura Shiori , Ohara Tomoyuki , Mizuno Toshiki
Published: January 2019

Purpose:
In stroke patients with cancer associated hypercoagulation, D-dimer levels were used as a marker of hypercoagulation, and heparin was reported to be more effective than warfarin for secondary prevention. After started heparin, D-dimer levels tend to decrease in such patients. However, the usefulness of D-dimer levels as an indicator of recurrent stroke has not been fully investigated. The aim of this study was to assess the usefulness of D-dimer levels in the setting of heparin treatment for stroke patients with cancer associated hypercoagulation.

Methods:
We retrospectively analyzed stroke patients with active cancer visited to our hospital within 7 days of onset, from 2008 to 2018. Active cancer was defined as a diagnosis of or treatment for any cancer within 6 months before stroke onset. Among the patients, we enrolled subjects who were treated with heparin and had elevated D-dimer levels (>2 μg/ml).

Results:
A total of 54 subjects (27 men, mean age 69 years) were registered. Most frequent cancer origin was pancreas (26%). Known metastatic disease was found in 67% of patients. The median pre-heparin D-dimer levels were 11.4μg/ml (IQR 5.5-20.7), and median post-heparin D-dimer levels were 8.0μg/ml (IQR 4.1-12.6). Recurrent stroke occurred in 13% patients during treated with heparin. As compared to patients without recurrent stroke, those with recurrent stroke during heparin treatment had higher ratio of post-heparin to pre-heparin D-dimer levels (1.03 vs 0.54 ; p<0.01). In logistic regression analysis, increase in the ratio of D-dimer levels (per 0.1) was significantly greater risk for stroke recurrence after adjusted for age and gender (Odds Ratio 6.5, 95%CI 1.5-43.8). Among patients without recurrent stroke, 30 patients were discontinued or changed heparin to other antithrombotic agents. Within few days of heparin discontinuation, recurrent stroke accompanied with D-dimer re-elevation was occurred in 5 patients despite of treated with other anticoagulants (Warfarin in 1 and direct oral anticoagulants in 4).

Conclusions:
During heparin treatment, the ratio of post-heparin to pre-heparin D-dimer levels was an indicator of recurrent stroke. After heparin was changed to other drugs, D-dimer re-elevation may be associated with recurrent stroke.
Abstract TP528: Differences in Stroke Severity According to the Prior Medication in Patients With Non-Valvular Atrial Fibrillation
Authors: Cho Bang-Hoon , Han Sang Won , Ahn Seong Hwan , Lee Kyung-Yul
Published: January 2019

Introduction:
Atrial fibrillation is one of the most common rhythmic disorders in general population and a major risk factor of ischemic stroke. We investigated whether there was any difference in initial stroke severity and short term outcome in patients with acute ischemic stroke and known non-valvular atrial fibrillation according to their prior medication status.

Methods:
We retrospectively reviewed patients with acute ischemic stroke and non-valvular atrial fibrillation who admitted at six hospitals from 2013 to 2016. We selected patients with known non-valvular atrial fibrillation before admission and a CHA
2
DS
2
-VASc score of ≥2. We categorized their prior medication status as follows: 1) no antithrombotics, 2) only antiplatelet, 3) warfarin with a subtherapeutic range, 4) warfarin with a therapeutic range, 5) under-dosed novel oral anti-coagulant (NOAC), and 6) standard-dosed NOAC. We compared the initial NIHSS score and 3 month modified Rankin Scale (mRS) between the groups.

Results:
Total 741 patients were enrolled for analysis. Patients were categorized as follows: 177 no antithrombotics, 296 only antiplatelet, 169 warfarin with a subtherapeutic range, 36 warfarin with a therapeutic range, 25 under-dosed NOAC, and 38 standard-dosed NOAC. Median NIHSS score was lowest in patients with standard-dosed NOAC (3, interquartile range [IQR] 1-7) compared to no antithrombotics (7, IQR 2-17), only antiplatelet (4, IQR 1-12.75), warfarin with a subtherapeutic range (6, IQR 2-15), warfarin with a therapeutic range (3.5 IQR 1-7), and under-dosed NOAC (7, IQR 2-16). Proportions of the patients with good functional outcome (mRS 0-2) are as follows; 45.5% no antithrombotics, 60.4% only antiplatelet, 56.5% warfarin with subtherapeutic range, 62.1% warfarin with therapeutic range, 40.9% under-dosed NOAC, and 64.7% standard-dosed NOAC.

Conclusions:
Large portion of non-valvular atrial fibrillation patients do not receive proper anticoagulation, although they have higher risk of embolization. Therapeutic anticoagulation reduces the initial severity of neurologic deficit in patient with ischemic stroke.
Abstract TP530: Transcranial Doppler Blood Velocities Kinetics During Treatment for Delayed Cerebral Ischemia in Patients With Subrachnoid Hemorrhage
Authors: Rouanet Carolina , Macedo Rejane , Alves Maramelia M , Valiente Raul , Neto Feres C , SIlva Gisele S
Published: January 2019

The role of Transcranial Doppler (TCD) in monitoring patients with subarachnoid hemorrhage (SAH) for delayed cerebral ischemia (DCI) is well established. However, the response and kinetics of TCD blood flow velocities (BFV) to treatment of DCI has been scarcely investigated. We assessed the hypothesis that TCD BFV decrease progressively after treatment of DCI with vasopressors or inotropics.

Methods:
All patients with SAH admitted to a tertiary hospital neurocritical unit were evaluated with daily TCD exams for monitoring for DCI from June 2016 to June 2018. DCI was defined as the development of new focal neurological signs and/or deterioration in level of consciousness, lasting for more than 1 h, or the appearance of new infarctions on neuroimaging. Patients who developed DCI and were treated with vasopressors or inotropics were prospectively included in this study. TCD exams were performed immediately before (t0), 1 hour (t1) and 2 hours after (t2) the initiation of therapy for DCI by the same neurosonologist. Clinical and physiological data before and during exams were recorded.

Results:
27 DCI treatments with either norepinephrine (n=12) or milrinone (n=15) in 21 patients were monitored. Patients were mainly females (88.9%, mean age 50.41+/- 12.52 year-old) with low grade clinical SAH (44.4% World Federation of Neurosurgeons Scale 1 and 2) but with high modified Fisher scores (81.1% with modified Fisher score of 3 and 4). DCI occurred 11.6+/- 3.4 days from the initial bleeding. Cerebral BFV significantly dropped after treatment (t0=158.08 +/- 42.84 cm/s; t1=146.71+/- 42.19 cm/s; t2=136.46+/-44.43 cm/s, p<0.01). There was also a significant drop in the National Institutes of Health stroke scale scores after therapy (t0= 13 [ 8, 19]; t1 12 [6, 19]; t2 9 [6, 19], p< 0.01). Patients treated with milrinone had a greater decline in cerebral BFV compared to those treated with norepinephrine (milrinone: t0 203.14+/- 49.41 cm/s; t1 183.14 +/-35.44 cm/s; t2= 167.86 +/- 37.55 cm/s, p=0.04 versus norepinephrine t0=156 +/- 27.45 cm/s; t1=164.58 +/- 40.48 cm/s; t2=159.0 +/- 48.24 cm/s, p=0.67).

Conclusion:
TCD BFV decrease progressively with hemodynamic therapy for DCI. Use of milrinone was associated with a greater decline in BFV when compared to norepinephrine.
Abstract TP532: Decreased Serum Sodium Levels Predict Symptomatic Vasospasm in Patients With Subarachnoid Hemorrhage
Authors: Uozumi Yoichi , Mizobe Takashi , Miyamoto Hirohito , Tatsumi Shotaro , Nakamura Mitsugu , Kohmura Eiji
Published: January 2019

Background:
Symptomatic vasospasm (SVS) is one of the major causes of morbidity and mortality in patients with subarachnoid hemorrhage (SAH). Hyponatremia and dehydration due to natriuresis after SAH is related to SVS and predicts it. Therefore, nowadays most institutions target to euvolemia and eunatremia in SAH patients to avoid complications. In this study, we retrospectively investigated the predictors of SVS in terms of water and sodium homeostasisunder maintaining euvolemia and eunatremia after SAH. We also analyzed the relationship between hyponatremia and the effect of treatment modality (clipping and endovascular coiling).

Methods:
We monitored changes in serum sodium levels, serum osmolarity, daily sodium intake, daily urine volume, and daily water balance during 14 days after SAH. Outcome was assessed using the modified Rankin scale one month after subarachnoid hemorrhage.

Results:
Among 105 patients, 29 (27.6%) had SVS. Patients with SVS were older than those without SVS and SVS affected outcome. Serum sodium levels were sequentially significantly decreased within normal range from one day before occurrence of SVS.Among the patients, 67 (63.8%) were treated with surgical clipping and 38 (36.2%) were treated with endovascular coiling. The group with coiling suffered significantly more severe hyponatremia and had less urine volume compared with the clipping group.

Conclusions:
SVS occurs more often in older patients and affects outcome. Serum sodium level decrease occurs one day before SVS. This observation may help predict SVS. A further large prospective study is necessary to resolve the detailed relationships among hyponatremia, urine volume, treatment modality and SVS in patients with SAH.
Abstract TP534: Comparing the Outcomes of Patients With Idiopathic Subarachnoid Hemorrhage by Three Distinct Perimesencephalic Bleed Patterns
Authors: Atchie Benjamin , McGraw Constance , McCarthy Kathryn , van Vliet Rebecca , Price Madison , Bennett Alicia , Bartt Russell , Orlando Alessandro , Wagner Jeffrey
Published: January 2019

Introduction:
Most studies on idiopathic subarachnoid hemorrhage (SAH) focus on comparing perimesencephalic bleeds (PSAHs) to aneurysmal SAHs. We divided PSAHs into three distinct bleed groups and compared clinical courses and outcomes.

Methods:
We included adult patients (≥18) with angiography-negative, non-traumatic SAH treated at a comprehensive stroke center (1/2015-5/2018). We excluded patients with known etiologies and convexity bleeds (N=41). Patients were categorized by bleed location on CTA: Peri-1: focal prepontine; Peri-2: pan-suprasellar cisterns; Peri-3: pan-suprasellar cisterns + sylvian fissures + intraventricular extension. Outcomes were cerebral ischemia (CI), hydrocephalus and severity, neuro critical care length of stay (NCCU LOS), and hospital LOS.

Results:
Of the 43 patients included in the study, 37% were Peri-1, 28% were Peri-2, and 35% were Peri-3. A majority were male (67%), with a median (IQR) age of 57 (44-63), and often presented with a headache (93%), nausea (72%), and a Hunt and Hess score of 1-3 (93%). Patients presenting with lethargy (6% vs. 17% vs. 67% p=0.006) and a modified Fisher score of 3 vs. 4 (100% vs. 92% vs. 33% p<0.001) were significantly different between groups in Peri-1-3, respectively. A history of hypertension (19% vs. 25% vs. 60% p=0.04) and mean (SD) days on nimodipine treatment (9.1(4.8) vs. 11.9(7.3) vs. 15.1(5.9), p=0.03) were significantly different between groups. Six (14%) patients had severe hydrocephalus and eight (19%) had CI. Median NCCU and hospital LOS, and proportion with hydrocephalus, were significantly different between groups. (Table 1). There were no other significant differences in outcomes between groups.

Conclusions:
Our study suggests that patients with the best outcomes were those in Peri-1, followed by Peri-2, and then Peri-3. Because there are no clear risk factors for PSAH, understanding differences by bleed patterns may help tailor better treatment strategies for this population.
Abstract TP54: Result of Clinical Trial Using Tron Fx, New Stent Retriver for Acute Ischemic Stroke
Authors: Sakai Nobuyuki , Imamura Hirotoshi , Matsumoto Yasushi ,   TRON FX Japanese Approving Trial Investigators
Published: January 2019

Objective:
To show safety and efficacy of mechanical thrombectomy (MT) for acute stroke using TRON-FX in Japanese approving trial.

Material and Methods:
This trial is multi center, prospective, single arm, registry study of new stent retriever, TRON-FX, Biomedical Solutions, Tokyo, Japan. TRON-FX have 2 size variation, 4mm diameter/20mm length and 2/15, smallest in the world. Inclusion criteria are 1) acute ischemic stroke (AIS) aged 20-85, 2) from onset to start MT within 8 hours, 3) IV rt-PA is ineligible or ineffective, 4) confirm occlude ICA, M1/M2/M3, VA, BA, and P1/P2. 5) NIHSS score 8 or more. Primary endpoint is immediate post procedural recanalization (up to 3 times by TRON-FX)and symptomatic intracranial hemorrhage (ICH) at 24 hours. Secondary endpoints are 1) good neurological outcome (mRS 0-2) at 90days, 2) symptomatic and asymptomatic ICH at 24 hours, 3) Mortality within 90days and 4) device-related or procedure-related serious adverse events at day 90.

Results:
50 patients enrolled and first patient in was 2017/9/27 and last patient in was 2017/11/5. All patient followed 90 days. Median age is 75, raged 44-86, male gender is 62% (31/50), occluded vessels are ICA(2) 4%, MCA/M1(23) 46%, MCA/M2M3(26) 52%, BA(3) 6%, PCA(1) 2%, IV rt-PA failed(37) 74%, median baseline NIHSS score is 17, ranged 8-29, and median mRS prior to stroke 0. The primary endpoint, recanalization TICI 2b or better was 40(80%), and symptomatic ICH was 1(2%). More over, the secondly endpoint, 1) mRS 0-2 at 90 days was 25/47(53.2%), 2) symptomatic and asymptomatic ICH was 15(30%), 3) mortality was 4(8%) and 4) no device-related or procedure-related serious adverse event.

Conclusions:
TRON FX approving trial in Japan has proved great efficacy and safety of this thrombectomy device with high recanalization rate with less intracranial hemorrhage, especially for distal and small vessel. Clinical Trial gov. IDNCT02964702
Abstract TP554: Etiologies of Nontraumatic Convexity Subarachnoid Hemorrhage
Authors: Forman Rachel , Song Sarah , Conners James , Lee Vivien
Published: January 2019

Introduction:
Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a non-aneurysmal variant associated with various etiologies.

Methods:
We performed retrospective review of consecutive cSAH admitted to a large comprehensive stroke center, from 8/1/06-1/1/16. We abstracted data on demographics, neuroimaging, and clinical presentation; trauma was excluded. Cases were categorized: cryptogenic (negative work-up), susceptibility-weighted imaging-confirmed amyloid angiopathy (AA), posterior reversible encephalopathy syndrome (PRES), imaging-confirmed reversible cerebral vasoconstriction syndrome (RCVS), cerebral venous thrombosis (CVT), large artery occlusion (LA), or other known cause (sepsis, endocarditis, cerebral infarcts, or malignancy).

Results:
We identified 84 cases of cSAH occurring in 83 patients. Etiology subgroups were: 25% cryptogenic (N=21), 16% AA (N=13), 13% PRES (N=11), 13% RCVS (N=11), 11% CVT (N=9), 8% LA (N=7), and 14% other (N=12). Among cryptogenic patients, 8 had suspected clinical RCVS and 1 had suspected AA. There were significant differences in age, gender, and clinical presentation among etiology subgroups. AA patients were the oldest (mean 75.6 years), while RCVS patients were the youngest (45.6 years, p<0.0001). The majority of AA cohort was male (61%), whereas PRES and RCVS cohorts were exclusively female (100%, p=0.0002). Transient neurologic symptoms were common in AA (69%) but rare in RCVS (0%, p=0.01); headache was common in RCVS (80%) but unusual in AA (15%, p=0.001). Among 11 patients with confirmed RCVS, initial vascular imaging was negative in 6 (55%); repeat vascular imaging was necessary to diagnosis vasoconstriction (mean delay 5 days, range 3 -16 days).

Conclusions:
To our knowledge, this is the largest case series of cSAH patients. Convexity SAH has a broad range of etiologies, with the most common being cryptogenic, RCVS, PRES, and AA. In our cohort, cSAH due to AA most typically presented as older males with transient neurological symptoms; cSAH due to RCVS presented as younger females with headache. Over half of patients with cSAH due to RCVS required repeat vascular imaging to confirm vasoconstriction. Further research is warranted to clinically characterize this complex variant of SAH.
Abstract TP556: Role of Vascular Smooth Muscle Cells in Diabetes-related Vascular Cognitive Impairment
Authors: Wang Shaoxun , Jiao Feng , Guo Ya , Booz George , Roman Richard , Fan Fan
Published: January 2019

The incidence of vascular cognitive impairment is increased 2-3 folds in type 2 diabetes, but the underlying mechanisms have not been fully elucidated. The present study examines whether chronic hyperglycemia and associated enhanced ROS production damage cerebral vascular smooth muscle cells (VSMCs) that promote impairment of cerebral autoregulation and contribute to cognitive deficits. The levels of glucose (422 ± 32 vs. 94 ± 3 mg/dL) and glycated hemoglobin (HbA1c, 11.5 ± 0.2 vs. 4.3 ± 0.1%) were higher in old (12-month) T2DN (n=15) in comparison with SD control rats (n=6). We found that the actin cytoskeleton was disorganized in VSMCs freshly isolated from middle cerebral arteries (MCAs) of T2DN compared with SD rats, similar to what was seen in normal primary VSMCs treated with high glucose or H
2
O
2
. Superoxide production was elevated in VSMCs and MCAs freshly isolated from diabetic rats. Elderly diabetic rats exhibit impaired myogenic response of MCA. Cortical blood flow measured by laser Doppler flowmetry rose by 137 ± 15% vs. 36 ± 5% in diabetic (n=6) vs. normal rats (n=6) when MAP was increased from 100 to 180 mmHg. T2DN rats exhibited higher levels of IL-1 β and IL-2, and marked neurodegeneration in the hippocampus and cortex. Elderly T2DN rats showed learning and memory impairments using 8-arm water maze testing. These results indicate that hyperglycemia and elevated ROS production induce VSMCs dysfunction in diabetic rats, which contribute to cerebral vascular dysfunction and promote development of cognitive deficits.
Abstract TP557: Endothelial Cell Proinflammatory Priming by Amyloidogenic Medin via NFκB and Inflammasome Pathways and Reversal by Monosialoganglioside Nanoliposomes
Authors: Karamanova Nina , Truran Seth , Madine Jillian , Davies Hannah , Zhang Weiyang , Franco Daniel , Weissig Volkmar , Migrino Raymond Q
Published: January 2019

Medin is a common amyloid protein that accumulates in cerebral vessels with aging and cause endothelial dysfunction in human cerebral arterioles. Studying its role in cerebrovascular disease could provide insights on cerebrovascular aging. We aim to test whether medin induces pro-inflammatory priming of endothelial cells (ECs) and probe mechanistic bases, and determine whether monosialoganglioside-containing nanoliposomes (NLGM1), previously shown to protect against AL amyloid vascular dysfunction, would abrogate this response.

Methods:
Human umbilical vein ECs were treated (20 hours) with physiologic dose of medin (5 μM) or vehicle, and proinflammatory markers IL-1β, caspase-1, IL-8, IL-6, ICAM-1, phospho-NFκB and pro-thrombotic marker plasminogen activator inhibitor-1 (PAI-1) gene and/or protein expressions were measured. In some replicates, medin was co-treated with either specific NFκB small molecule inhibitor RO106-9920 100 μM or NLGM1 (70:20:5% phosphatidylcholine, cholesterol, monosialoganglioside, 1:10 medin:NLGM1 mass ratio).

Results:
Medin increased gene expression of IL-1β (104.0±30.2x vs. control, p=0.002), IL-8 (5560±1864x, p<0.001), IL-6 (80.4±48x, p<0.001), ICAM-1 (72.0±8.5x, p<0.001) and PAI-1 (5.4±1x, p<0.001) (n=13-44). There were corresponding increases in protein expression as well as increased phospho-NFκB and caspase-1 (Figure). RO106-9920 co-treatment reduced gene expressions of IL-8, IL-6, ICAM-1 and PAI-1 but not IL-1β (versus medin treatment) whereas NLGM1 normalized gene expressions of all cytokines including IL-1β.

Conclusions:
Medin induced profound proinflammatory and prothrombotic responses in endothelial cells. Both NFκB and inflammasome-mediated mechanisms mediate medin’s vascular priming effects. Medin-induced pathology is a potential new mechanism of aging-related cerebrovascular inflammation. NLGM1 protects against medin’s effects and may represent a new therapeutic approach.
Abstract TP558: Association of Blood Pressure and Cognition After Stroke
Authors: Levine Deborah A , Galecki Andrzej T , Okullo Dolorence , Briceno Emily , Kabeto Mohammed U , Langa Kenneth M , Morgenstern Lewis B , Giordani Bruno , Brook Robert D , Sanchez Brisa , Lisabeth Lynda D
Published: January 2019

Background:
It is unclear whether blood pressure is associated with cognitive function after stroke.

Methods:
Cross-sectional analysis of prospectively obtained data of 432 subjects (mean age, 66; 46% female) with stroke (92% ischemic; median NIH stroke score, 3 [IQR, 2-6]) aged 45 or older without dementia from the population-based Brain Attack Surveillance in Corpus Christi project in 2011-2013. We examined associations between systolic and diastolic blood pressure (BP) and cognitive performance each measured 90 days after stroke. BP measured 3 times using standard protocol and averaged. Cognition was assessed using 4 tests: Modified Mini-Mental Status Examination (3MSE), animal fluency test, Trails A and B. Linear or tobit regression adjusted associations for age, education, and race/ethnicity as well as variables that were significantly associated with both BP and cognition.

Results:
Systolic BP was not significantly associated with cognitive performance (Model 1) unless diastolic BP was included in the model (Model 3)(Table). Both higher systolic BP and lower diastolic BP each were significantly associated with worse cognitive performance for all 4 tests (Model 3). Diastolic BP remained significantly associated with cognitive performance after adjusting for age, education, and race/ethnicity but systolic BP did not (Model 4). With further adjustment for clinical factors, diastolic BP did not remain independently associated with cognition (Model 5). Lower cognitive performance was significantly associated with older age, less education, Mexican American ethnicity, diabetes, higher stroke severity, more depressive symptoms, and lower BMI.

Conclusion:
Patients with higher systolic BP and lower diastolic BP are more likely to have worse cognitive performance after stroke but sociodemographic and clinical factors may explain these associations.
Abstract TP559: Sulforaphane Confers Neuroprotection Against Neuronal Loss, White Matter Injury and BBB Damage Following Experimental Vascular Cognitive Impairment
Authors: Mao Leilei , Yang Tuo , Li Cong , Zhang Feng , Sun Baoliang
Published: January 2019

Sulforaphane reduces brain injury following experimental vascular cognitive impairment by activating Nrf2 pathway

Aims:
Vascular cognitive impairment (VCI) is a type of dementia, and its major pathophysiological process is chronic ischemia, leading to the blood-brain barrier (BBB) disintegration, neuronal death, and white matter injury. The aim of current study is to test whether sulforaphane (Sfn), a natural activator of nuclear factor erythroid 2-related factor 2 (Nrf2), protects the brain against chronic ischemic injury and improve cognitive function after experiment VCI.

Results:
VCI was induced in rats by permanent occlusion of both common carotid arteries, which caused remarkable cognitive impairment, accompanied by neuronal death in the cortex and hippocampal CA1, demyelination in the corpus callosum and hippocampal fimbria, and accumulation of myelin debris in the corpus callosum. Sfn alleviated the cognitive impairment and reduced these accompanying pathophysiological changes. Sfn neuroprotection was associated with enhanced Nrf2 activation. In vitro, Sfn reduced neuronal and endothelial death, maintained the integrity of the BBB after oxygen-glucose deprivation; and Nrf2 knockdown with shRNA significantly reduced the protection of Sfn. Furthermore, Nrf2 knockdown in endothelial cells decreased the level of claudin-5, a tight junction protein; and luciferase assay suggested that claudin-5 might be a downstream target of Nrf2. Innovation: This is the first study demonstrates the neuroprotective effects of Sfn against neuronal loss, white matter injury, and BBB damage after VCI. Furthermore, it discovers the accumulated myelin debris in WM and that Nrf2 may control the expression of claudin-5.

Conclusion:
Our results suggest that Sfn provides comprehensive protection to the brain and may be a promising agent targeting cognitive impairment.
Abstract TP564: Diabetic but Not Control Rats Develop White Matter Injury and Cognitive Deficits in a Microemboli Injection Model of VCID
Authors: Li Weiguo , Ahmed Heba , Lin Ping-Chang , Dong Guangkuo , Ara Roxan , Arbab Ali , Ergul Adviye
Published: January 2019

Diabetes doubles the risk of vascular cognitive impairment and dementia (VCID), a disease is associated with small vessel disease (SVD) of the brain. Given that diabetes mediates early cerebrovascular dysfunction, and microemboli are common in the cerebral circulation and can penetrate into the brain parenchymal arterioles without causing an infarction, we tested the hypothesis that entrapment of microemboli in dysfunctional vessel walls accelerates the development of SVD ultimately resulting in VCID in diabetes. Diabetes was induced by a high fat diet and low dose streptozotocin (35 mg/kg, IP) injection in male Wistar rats. Cholesterol crystal microemboli [40-70 μm, 3000 (Group A) or 6000 (Group B) per 200 μl saline] were injected 8 weeks later through internal carotid artery. Cognitive function was monitored by the novel object recognition (NOR) test. White matter injury was assessed by Luxol fast blue (LFB) and hematoxylin/eosin (HE) staining in Group A. Cerebral blood flow (CBF), white matter hyperintensities (T2 map), microbleeds (T2 asterisk), and microinfarcts (T2 W) were assessed by MRI in Group B. In Group A, there was increased white matter degeneration in diabetic animals compared to controls. This degeneration was aggravated by microembolic injection. We found that cognitive function was exacerbated in Group B diabetes animals. MRI results showed these animals also had decreased CBF but no change on microinfarcts or microbleed. These results suggest that white matter degeneration starts in the early stages of diabetes, and that microemboli exacerbate these pathological changes even before the appearance of any neurobehavioral deficits. Additional studies are needed to examine the precise time course for development of cerebral neurovascular changes relative to appearance of behavioral deficits and explore potential therapeutic targets for VCI in diabetes.
Abstract TP569: The Evaluation of Cognitive Function Using Neural Network Analysis Before & After Revascularization Surgery for Internal Carotid Artery Stenosis
Authors: Kohta Masaaki , Fujita Atsushi , Hosoda Kohkichi , Kohmura Eiji
Published: January 2019

Background:
Internal carotid artery stenosis (ICS) can lead to cognitive impairment as well as ischemic stroke. Although carotid revascularization surgery, such as carotid endarterectomy (CEA) and carotid artery stenting (CAS), can prevent future strokes, the effect of revascularization on cognitive function is controversial. In recent years, the analysis of functional connectivity (FC) in resting-state functional MRI (rs-fMRI) has been used to investigate the effects of cognitive interventions. In this study, cognitive function is evaluated in ICS patients undergoing revascularization surgery with rs-fMRI.

Methods:
A prospective study was conducted among 17 ICS patients who were expecting revascularization surgery. Cognitive assessment, including the Mini-Mental State Examination (MMSE), the Frontal Assessement Battery (FAB), and the Japanese version of the Montreal Cognitive Assessment (MoCA-J) and rs-fMRI were administered ≤ 1 week preoperatively and postoperatively at 3 months. For the analysis of FC, a seed region was placed in the posterior cingulate cortex (PCC) associated with cognitive function.

Results:
After revascularization surgery, significant improvement in the score of MMSE (28.1 vs 29.1, P = 0.01) and MoCA-J (24.0 vs 26.7, P = 0.001) was found. No significant difference was found in the score of the FAB (16.2 vs 16.8, P = 0.09) between before and after surgery. According to the analysis of FC, ICS patients showed increase of connectivity between PCC and posterior cingulate gyrus, and between PCC and precuneus postoperatively at 3 months.

Conclusion:
Revascularization surgery for ICS improves cognitive function. The cognitive improvement may be partly attributed to the increase of connectivity between PCC and posterior cingulate gyrus/precuneus.
Abstract TP572: Electrocardiogram T Wave Abnormalities are Associated With the Total Burden of Cerebral Small Vessel Disease in Patients With Acute Ischemic Stroke or Transient Ischemic Attack
Authors: Sarkar Monica , Salloum Christine , Powell Kimerly A , Torbey Michel T , Hannawi Yousef
Published: January 2019

Introduction:
Electrocardiogram (ECG) abnormalities are commonly seen in patients with acute ischemic stroke (AIS). We aimed to determine the influence of the underlying brain state as measured by the total cerebral small vessel disease (CSVD) burden on ECG abnormalities in patients with AIS or Transient Ischemic Attack (TIA).

Methods:
Patients with AIS and TIA were prospectively enrolled in a hospital-based stroke registry. Total CSVD burden was measured according to Staals et al on the first brain MRI obtained within 48 hours from hospital admission. Stroke volume was measured on the DWI sequences using ABC/2 formula according to Sims et al. ECG abnormalities were noted on the first ECG obtained in the Emergency Department. Additionally, PR and QTC intervals and QRS complex duration were measured. Univariate analysis was used to test the relationships between total CSVD burden and ECG abnormalities. Linear regression and binary logistic regression models were used for the variables that were significant in univariate analysis to adjust for age, sex, race, current smoking, history of atrial fibrillation, coronary artery disease, valvular disease, myocardial infarction, hypertension, diabetes, hyperlipidemia, antihypertensive medications, stroke volume and involvement of the insula by the stroke.

Results:
141 patients (age 64.5±15.3, 49% females, total CSVD burden was 1.6±1.4, stroke volume 21±40.6, heart rate 79.6±16.5, PR interval 168.4±27 ms, QRS complex 94.1±19.2 ms, QTC interval 450±37.1 ms, abnormalities of ST, T wave, right ventricular hypertrophy, left ventricular hypertrophy, bundle branch block and myocardial infarction were seen in 19.8%, 26.5%, 1.7%, 9.2%, 6.7% and 24.2%). Rhythm was sinus in 72.7% and atrial fibrillation in 8.6%. In univariate analysis, there was significant relationship of total CSVD score with QTC interval and T wave abnormalities (P values: 0.01 and 0.0036 respectively). The relationship of T wave abnormality with total CSVD burden remained significant in logistic regression analysis (OR: 2.2, 95% CI: 1-4.8, P: 0.05).

Conclusions:
Total CSVD burden is associated with ECG T wave abnormalities in TIA and AIS patients. Further research is required to identify the underlying pathophysiological mechanisms.