bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract TP411: Distinct Systolic Blood Pressure Trajectories 72 Hours After Mechanical Thrombectomy Predict Hemorrhagic Transformation and Poor Functional Outcome
Authors: Kodali Sreeja , Wang Anson , Strander Sumita , Silverman Andrew , Agarwal Tijil , Stretz Christoph , Sansing Lauren H , Schindler Joseph L , Sheth Kevin N , Petersen Nils H
Published: January 2019

Introduction:
Current stroke guidelines recommend maintaining systolic blood pressure (SBP) below 180 mmHg after thrombolysis, and this standard has carried over for post-thrombectomy blood pressure (BP) management. However, optimal BP management after mechanical thrombectomy (MT) remains unclear and BP beyond 24 hours after thrombectomy is not well-studied. We investigated how 72-hour SBP trajectories after MT may predict patient outcome.

Methods:
We retrospectively studied patients with large-vessel occlusion stroke who underwent MT. BP was non-invasively recorded hourly for the first 72 hours. Hemorrhagic transformation (HT) was measured on 24-hour CT scans using ECASS II classification. Functional outcome was assessed using the modified Rankin Scale (mRS). SBP trajectories between groups were compared using generalized estimating equations. All analyses were adjusted for age, admission NIHSS, and recanalization status.

Results:
Seventy-three patients (mean age 72±14, 40F, mean NIHSS 18) were analyzed. Patients with poor 90-day functional outcome (mRS >3) had higher mean SBP over the first 24 hours compared to those with favorable outcome (136 vs. 128 mmHg, p=0.017) and demonstrated distinct BP trajectories over the first 72 hours (Figure 1A). Patients with poor functional outcome had higher SBP directly after MT (155 vs. 141 mmHg) and their pressures dropped less during the first 12 hours when compared to those with favorable outcomes (p=0.018). Similarly, mean SBP and SBP trajectories of patients with HT were significantly different from those without HT (Figure 1B, p=0.050). By 72 hours, SBP trajectories were similar, regardless of functional outcome or HT.

Conclusions:
During the first 72 hours after MT, acute ischemic stroke patients show distinct SBP trajectories, which differ in relation to functional outcome and hemorrhagic transformation. The findings may help recognize potential candidates for future blood pressure control trials.
Abstract TP413: Prediction of Dysphagia Using the
Alberta Stroke Program Early CT Score
Authors: Lapa Sriramya , Foerch Christian , Singer Oliver C , Hattingen Elke , Luger Sebastian
Published: January 2019

Background:
Dysphagia is common in patients with acute middle cerebral artery (MCA) stroke, and associated with malnutrition, pneumonia and mortality. Hence, identification of patients with swallowing disorder early after stroke onset is important. Besides bedside screening tools, brain imaging findings including lesion size and location may be of value. We investigated whether The Alberta stroke program early CT score (ASPECTS) can be used to predict dysphagia, and whether differences exist herein between the left and the right hemisphere.

Methods:
The analysis was based on a prospective dataset of 113 patients with acute ischemic stroke in the MCA territory. Fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 24 h after admission for validation of dysphagia. Brain imaging (CT or MRI) was rated for ischemic changes according to the ASPECT score.

Results:
62 patients (54.9%) had FEES-proven dysphagia. In left hemispheric strokes the strongest associations between the ASPECTS sectors and dysphagia were found for the lentiform nucleus (ExpB 0.113 [CI 0.028-0.433; p=0.001), the insula (0.275 [0.102-0.742]; p=0.011) and the frontal operculum (0.280 [CI 0.094-0.834]; p=0.022). For right hemispheric strokes, only non-significant associations were found which were strongest for the insula region (0.385 [0.107-1.384]; p=0.144). For the left hemisphere multivariate logistic regression analysis revealed lower ASPECT scores to be independently associated with dysphagia, whereas for the right hemisphere this association was not present.

Conclusion:
The distribution and extent of early ischemic changes in brain imaging according to ASPECTS allows a reliable prediction of dysphagia in MCA-stroke patients, particularly for the left hemisphere.
Abstract TP422: Mechanisms of Cerebral Microbleeds
Authors: Grigoryan Mher , Paganini-Hill Annlia , Kim Ron C , Kim Jeff , Corrada Maria , Fisher Mark
Published: January 2019

Cerebral microbleeds are a common MRI finding in the aging population, and reflect an underlying microscopic pathology of cerebral microhemorrhage. Pathogenesis of cerebral microbleeds remains obscure. We conducted a mechanistic investigation of the neuropathology of cerebral microhemorrhage, combining standard and immunohistochemistry analyses, and focusing on microvascular changes concurrent with microhemorrhage. We conducted a postmortem study of participants from the UCI Alzheimer’s Disease Research Center and The 90+ Study. We analyzed five brain regions (middle frontal gyrus, occipital pole, rostral cingulate cortex, caudal cingulate cortex, and basal ganglia) of 77 brain bank subjects (aged 90±10.8 years, mean±SEM ). Prussian blue-positivity, used as an index of cerebral microhemorrhage, was subjected to quantitative analysis for all five brain regions and compared with quantitative immunohistological findings of smooth muscle actin, claudin-5, fibrinogen, and platelet-derived growth factor receptor-beta (PDGFRβ), along with the sclerosis index, a measure of arteriolar injury. The top and bottom quartiles (n=19 each) for Prussian blue-positivity were compared for immunohistological findings and for sclerosis index. Subjects from the top quartile (ie, with most extensive cerebral microhemorrhage) had significantly higher sclerosis index in all five brain regions collectively (0.355±0.008 vs 0.379±0.007; p<0.05). In addition, PDGFRβ, an index of pericyte presence, was significantly lower in the top versus bottom quartiles in caudal cingulate cortex (82±7 vs 136±15 um
2
, p<0.01). The top and bottom quartiles did not differ significantly for smooth muscle actin, fibrinogen, or claudin-5 immunoreactivity. These findings indicate significant coexistence of arteriolar injury and cerebral microhemorrhage, as well as suggesting pericyte loss concurrent with cerebral microhemorrhage. Further studies are needed to determine the presence of causal roles for arteriolar injury and pericyte loss in the pathogenesis of cerebral microbleeds.
Abstract TP432: Dilated Optic Nerve Sheath Diameter by Trans-Orbital Ultrasound Predicts Mortality Among Patients With Acute Intracerebral Hemorrhage
Authors: Dias Francisco A , Barreira Clara M , Zontin Maria Clara Z , Alessio-Alves Frederico F , Martins Rui K , Boulouis Gregoire , Venturelli Paula M , Flores Alan , Lavados Pablo , Goldstein Joshua N , Pontes-Neto Octavio M
Published: January 2019

Introduction:
Supratentorial Intracerebral hemorrhage (ICH) main prognostic factors on admission are age, Glasgow coma scale (GCS), ICH volume and ventricular hemorrhage. Subsequent ICH expansion and associated elevated intracranial pressure (ICP) have also been linked to poorer outcomes. Dilatation of optic nerve sheath diameter (ONSD) by trans-orbital ultrasound examination is an increasingly recognized marker of elevated ICP. We sought to evaluate whether increased ONSD at hospital admission could be associated with mortality among patients with supratentorial ICH.

Methods:
Prospective cohort of consecutive acute supratentorial ICH patients admitted to a tertiary stroke center. Exclusion criteria: 1) last well seen > 24 hours; 2) immediate surgical intervention indicated by neurosurgery team; 3) Secondary ICH (anticoagulants and antiplatelets were allowed); 4) previous optic nerve pathology precluding accurate ONSD measurements. Ultrasound assessment and CT performed within the first hour after admission. Primary outcome was 90-days mortality. Multivariate logistic regression, ROC curve and c-statistics was used to identify independent predictors of mortality.

Results:
Between July 2014 and July 2017, 57 patients were evaluated. Among those, 13 were excluded and 44 were recruited into the trial. Their mean age was 62.3± 13.1 years and 32 (72.7%) were male. On univariate analysis, ICH volume on admission CT scan, ICH ipsilateral ONSD measurement on admission TCCD, diabetes and current smoking were predictors of mortality. After multivariate analysis, ipsilateral ONSD (OR:6.24;95CI%1.18-33.1;p=0.031) was an independent predictor of mortality, even after adjustment for ICH volume, age, GCS and intraventricular hemorrhage. The ONSD had an area under the curve (AUC) of 0.71 (p=0.021) for mortality at 3 months.

Conclusion:
ONSD is a non-invasively, bedside, low cost technique that could be used to estimate increased ICP in patients with acute supratentorial ICH. Among these patients, increased ONSD is an independent predictor of mortality at 3 months.
Abstract TP438: Cigarette Smoking History and Functional Outcomes After Spontaneous Intracerebral Hemorrhage
Authors: Chen Ching-Jen , Ding Dale , Ironside Natasha , Buell Thomas J , Southerland Andrew M , Koch Sebastian , Flaherty Matthew , Woo Daniel , Worrall Bradford B ,   ERICH Investigators
Published: January 2019

Objective:
While cigarette use may be a risk for intracerebral hemorrhage (ICH), animal models suggest that nicotine has a potential neuroprotective effect. The aim of this multicenter study is to determine the effect of smoking on outcome in ICH patients.

Methods:
We analyzed prospectively collected data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, and included patients with smoking status data in the analysis. Patients were dichotomized into non-smokers versus ever-smokers, and the latter group was further categorized as former (>30 days before ICH) or current (≤30 days before ICH) smokers. The primary outcome was 90-day modified Rankin Scale (mRS) score shift analysis. Secondary outcomes were in-hospital mortality and mortality, Barthel Index, and self-reported health status measures at 90 days.

Results:
The overall study cohort comprised 1,509 non-smokers and 1,423 ever-smokers (841 former, 577 current, 5 unknown). No difference in primary outcome was observed between non-smokers versus ever-smokers (aOR=1.041 [0.904-1.199], p=0.577). No differences in primary outcome were observed between former (aOR=0.932 [0.791-1.178], p=0.399) or current smokers (aOR=1.178 [0.970-1.431], p=0.098) versus non-smokers. Subgroup analyses by race/ethnicity demonstrated no differences in primary outcome when former and current smokers were compared to non-smokers. Former, but not current, smokers had a lower in-hospital mortality rate (aOR=0.695 [0.500-0.968], p=0.031), which was only observed in Hispanics (aOR=0.533 [0.309-0.921], p=0.024). Differences in self-reported health status measures were only observed in whites.

Conclusion:
Cigarette smoking history does not appear to provide a beneficial effect on 90-day functional outcome in patients with ICH.
Abstract TP448: Post-Stroke Fall Prevention Strategies
Authors: Pruett Sonia J , Goswami Amartyadeb , Holmes Rebecca
Published: January 2019

Background:
Fall prevention strategies are developed to prevent falls in the general patient population. Stroke patients, however, present with unique deficits that increase their potential for falls. There is strong evidence that creating a better understanding of the factors contributing to post stroke falls, and pairing stroke specific interventions with current fall prevention strategies, will result in improved patient safety.

Purpose:
The primary Objective of this study was to identify the unique characteristics of stroke patients that place them at higher risk for falls, and develop strategies and practices that reflect awareness of stroke deficits. The secondary Objective of this study was to demonstrate the feasibility of preventing harm through reducing the opportunity for injury.

Methods:
This study reviewed 174 falls occurring from 2015 to 2018 in an Inpatient Rehabilitation unit (IRU) and an Ortho/Neuro unit. The data was obtained through post fall huddle reports which include: diagnosis, gender, stroke location, circumstances precipitating the fall, National Institute of Stroke Scales (NIHSS), and timing of fall.

Results:
Of 174 falls on the IRU and Ortho/Neuro units, 51% [88/174] of the patients had a stroke diagnosis, 49% [85/174] were identified as “other”. Exclusion of “other” diagnosis resulted in a sample size of 88 patients, comprised of 44% female and 56% male. Of the patients included, 10% had bilateral infarcts, 41% right brain, and 43% left brain infarcts. The circumstances precipitating falls included: 22% during transfers, 32% during toileting, and 36% from falling out of bed/chair, or were unattended. NIHSS and timing of fall were not found to be statistically significant in this study.

Conclusion:
Identification of a stroke patient’s potential for falling, and development of prevention strategies, may increase the safety on the unit. In addition to current fall prevention strategies, stroke patients should have toileting and purposefully rounding plans developed prior to the start of shift, with an emphasis on transferring and toileting assistance needs. These plans should be shared during shift huddles and bedside report. Due to the relatively small sample size, further studies would be benefited by a larger sample group.
Abstract TP449: 3-month Medication Persistence and Medication Adherence in Korean Ischemic Stroke Survivors
Authors: Yoo Sung-Hee , Kim Kye-Gyung , Kim Sung-Reul , Park Man-Seok , Kim Joon-Tae , Park Hyun-Young , Yi Sang-Hak , Cha Jae-Kwan , Kim Dae-Hyun , Nah Hyun-Wook
Published: January 2019

Purposes:
This study aimed to investigate persistence and adherence of medication at 3 months after acute stroke, and to identify the predictors of poor medication adherence in Korean ischemic stroke survivors.

Methods:
As a part of a prospective, longitudinal observation study, data collected from September 1
st
, 2017 to June 30, 2018 at three stroke center in Korea were analyzed for the 3-month outcome measure. Medication persistence and medication adherence with Morisky medication adherence scale-8 items (MMAS-8) were assessed at 3 months after hospitalization due to acute ischemic stroke including transient ischemic attack (TIA). For identifying the predictors of poor medication adherence, various and potential factors suggested by WHO as related factors of medication adherence were investigated during admission by face-to face interview.

Results:
Of a total of six hundred patients, male was 390 (65.0%), and mean(±SD) age was 65.6(±12.9) years. Of 544 survivors followed up at 3-month, 531(97.6%) was persistent with their medication, but only 479(88.1%) were good at medication adherence. Old age(p=.001), job(p=.007), TIA than ischemia(p=.034), NIHSS (p=.035) and mRS(p=.003) scores at discharge, low medication belief(p=.001) and literacy(p.030), high drug cost(p=.041), and low income(p=.009) were related with poor 3-month medication adherence by univariate analysis. However, only mRS at diacharge [OR(95% CI)=0.586(0.349-0.985), p=.043] and medication belief [OR(95% CI)=0.941(0.893-0.991), p=.022] were independent predictors.

Conclusions:
In Korean stroke survivors, 3-month medication adherence was relatively poor. For improving this, a variety of strategies are needed to improve the beliefs about the drug, considering individual stroke sequelae and literacy levels.
Abstract TP453: Patient Stroke Education: Personal Modifiable Risk Factors
Authors: Zamudio Alyssa , Kimball Kathleen , Hastings Melissa , Mackay Kristen , North Kelly , Escalera Sabrina , Hackett Sandra , Forland Kayla , Mcleod Audra , Kaura Valerie , Belardo Gayle
Published: January 2019

Objective:
To improve stroke education by focusing on identification and management of personal modifiable risk factors, through creating a teaching tool for our stroke patient population and those at risk for stroke.

Background:
One of the challenges facing those involved in stroke care is improving patient understanding of their personal risk factors and reducing their chance of having another stroke. Our Stroke program recognized that some stroke patients were unable to identify their modifiable risk factors during the stroke discharge follow up calls. 2100 staff initiated a nurse-led process on stroke education. With implementation of an interactive teaching tool developed by the staff, the goal is for stroke patients to identify and provide teach back on recognition and response to stroke signs and symptoms as well as their modifiable stroke risk factors

Methods:
A teaching card was created (adapted from American Heart Association and American Stroke Association), for the nurse to review and educate the patient on stroke recognition and response, identifying and managing their modifiable risk factors. A unit wide audit was conducted at time of discharge. Using the Plan-Do-Study-Act method and the stroke program discharge callback process, the stroke program and the unit staff continue to evaluate the effectiveness of the stroke education card.

Results:
Starting in 2018 when the teaching tool card was implemented, 2100 Stroke Discharges responses on Stroke Recognition and Response has increased to 100% for the first 3 months of year. More importantly, in the first quarter of 2018, 2100 Stroke Discharges have been able to identify their personal modifiable risk factors.

Conclusions:
The results of this project suggest that use of this teaching tool can be beneficial on knowledge retention and understanding of education provided on stroke recognition, response, and identification and management of their personal modifiable stroke risk factors.
Abstract TP466: Smoking and Clopidogrel Effect in Ischemic Stroke
Authors: Kang Hyun Goo , Ha Sang Woo , Kim Bum Joon
Published: January 2019

Background:
The importance of antiplatelet failure due to antiplatelet resistance may differ between those receiving mono antiplatelet and dual antiplatelet treatment (DAPT). Smoking is a well-known factor which influences the resistance of clopidogrel. Here, we compared antiplatelet resistance between those who receive mono and dual antiplatelet treatment and between smokers and non-smokers

Methods:
We have consecutively enrolled patients who experienced ischemic stroke under antiplatelet treatment. First, patients were divided in to three groups according to the antiplatelet treatment at the time of stroke; aspirin, clopidogrel and DAPT. Demographics, conventional risk factor and aspirin (ARU) and P2Y12 reaction unit (PRU) measured by
VerifyNow
was compared between the three groups. Among those who received DAPT, patients were dichotomized to smokers and non-smokers. ARU and PRU were compared between the two groups.

Results:
Among 783 patients, 485 patients were under aspirin, 133 patients under clopidogrel and 165 patients under DAPT. There was no significant difference in demographics and risk factor among three groups. However, ARU was higher in those under aspirin than DAPT (482.00±73.12 vs. 453.02±82.94; p=0.001), and PRU was higher in those under clopidogrel than DAPT (257.79±92.82 vs. 225.71±87.71; p=0.013). Among those under DAPT, 88 patients were non-smokers and 76 patients were smokers. Smokers were younger, more male, but had less hypertension. The ARU was similar between the two groups, PRU was significantly lower in the smoker group (195.95±80.66 vs. 245.98±85.31, p=0.004).

Conclusion:
Antiplatelet resistance may be more important in those receiving mono antiplatelet than in those receiving DAPT. Therefore, selecting antiplatelet agent may be more critical in those receiving mono antiplatelet. Smoking paradox was also confirmed in stroke population and can be considered in determining antiplatelet treatment strategy.
Abstract TP470: The Value of Perfusion Ct as a Prognostic Factor After Mechanical Thrombectomy in Anterior Circulation
Authors: Park Sang Kyu , Nam Yun Jung
Published: January 2019

Introduction:
Mechanical thrombectomy is recommended as first line treatment for large vessel occlusion(LVO) patients. Mechanical thrombectomy is performed based on the ASPECT score to achieve recanalization of the blood vessels at a faster rate. However, in patients with ASPECT score of 6 or more, the infarction volume on the diffusion MRI can occur throughout the MCA territory, resulting in hemorrhage after the thrombectomy and low cost effectiveness. Therefore, we conducted a study to determine whether recanalization was faster and whether perfusion CT could be used as a predictor of prognosis.

Method and Material:
We retrospectively studied patients who had recanalization therapy with LVO of anterior circulation at our hospital from 2011 to 2015. The cerebrovascular accident(CVA) protocol was activated when LVO was suspected, and non-enhance CT, perfusion CT, and CT angiography were performed. The CVA CT scan takes a 7 minutes. In these patients, 10 areas such as ASPECT score were designated and scores were given to the lowered areas of CBF, MTT, and CBV compared with the contralateral side, and scoring was performed at 10 points. EMR and imaging study of patients with ASPECT score of 7 or more were confirmed. We checked NIHSS at admission, mRS at discharge, and mRS at 90 days after discharge.

Results:
In total, 94 patients met the inclusion criteria of this study. After recanalization, TICI G 2b and 3 were achieved 80 patients (85.10%). Of the total patients, 71 patients (75.53%) had a CBV score of 4points or less and 23 patients (24.47%) had a score of 5points or more. In patients with CBV 4 points or less, good outcome(mRS 0 ~ 2) was 34 patients (47.88%). In patients with CBV 5 points or more, good outcome(mRS 0 ~ 2) was 6 patients(26.08%). The mortality rate was 7.04%(5patients) in patient with CBV 4points or less, but there were 30.43%(7patients) in patients with CBV 5points or more.

Conclusion:
Mechanical thrombectomy showed better prognosis in LVO patients with CBV score of 4 points or less. But there is showed higher mortality rate in patients with CBV score of 5 points or more. Perfusion CT can be helpful in predicting the prognosis of the patient.
Abstract TP480: Standardizing Inpatient Stroke Alert Processes Yields Faster Treatment Times in Inpatient Strokes
Authors: Sessa Joy , Mehta Brijesh P , Lima Andrey , Canellas Victoria
Published: January 2019

Background:
In-hospital strokes account for 6.5%-15% of all strokes. Efficiently managing inpatient stroke alerts is a resource-intensive process involving multidisciplinary teams. Standardized emergency department (ED) stroke protocols have been shown to decrease time from stroke alert (SA) activation to neuroimaging and treatment. At our institution, stroke patients arriving to the ED were evaluated and treated faster than inpatient (IP) strokes, highlighting the need for an improved IP SA process to meet work flow benchmarks established by the American Stroke Association.

Purpose:
Standardizing the IP SA process will decrease time to CT imaging and neurological evaluation, reducing SA activation to treatment times for IP strokes.

Methods:
A revised in-hospital SA protocol was implemented 8/2016 to prioritize early neurology notification and CT imaging. A total of 332 inpatient SA cases from 1/2013-6/2018 were analyzed for: SA activation to neurology contact, SA activation to CT image scout film time, SA activation to thrombolytic (tPA) administration and/or groin puncture time in cases where a mechanical thrombectomy was performed.

Results:
Analysis showed significant improvements to all of the outcome measures: 35% improvement in IP SA activation to CT imaging start time (N= 167 prior to protocol revision; N=165 after protocol revision), 36% improvement in SA activation to neurology contact time, 59% improvement in SA to tPA administration time (N=7 prior to protocol revision; N=11 after protocol revision), and a 10% improvement in SA to groin puncture time for thrombectomy cases (N=6 cases prior to protocol revision; N=6 after protocol revision). A 36% increase in IP tPA administrations might be attributed to rapid consideration of eligibility within the treatment window.

Conclusions:
Standardizing IP SA processes to remove inefficiencies optimizes work flow across all phases of evaluation and leads to faster treatment times and increased treatment rates. These findings may serve as the basis for large-scale multicenter studies to further validate effective protocols’ impact on patient outcomes.
Abstract TP483: Improving Patient Stroke Education by Acute Care Nurses
Authors: Vann Jessica , Diegel-Vacek Lauren
Published: January 2019

Background and Issues:
Patient education is a vital component of preventing a future stroke for survivors of ischemic stroke. Each year, twenty-five percent of strokes diagnosed in the United States are secondary strokes. Hospital-based interventions in the acute phase of care post-stroke can help reduce the likelihood of secondary stroke. Teaching patients tactics for decreasing their stroke risk is one such intervention.

Methods:
This project utilized the Plan-Do-Check-Act (PDCA) quality improvement model. Educational in-services were conducted by the project leader on two nursing units and the float pool. An education initiative was developed using evidence based guidelines to improve nursing knowledge of patient education best-practices and the guidelines from the Centers for Medicare & Medicaid Services (CMS) & The Joint Commission regarding patient stroke education and documentation. Nursing knowledge before and after the education initiative was evaluated using a pre-test/post-test survey and nursing satisfaction with the education program was evaluated using a Likert survey.

Results:
Thirty-seven RNs attended the educational in-services and 27 of those completed a pre & post-test. The average improvement seen after the education was 14.7% (pre-test score 73.1%, post-test 87.8%). The RNs rated their satisfaction an average of 4.5 on a 5 point scale. There was no correlation between years of nursing experience and scores on the pre/post-test. This demonstrates the educational initiative was valuable for staff nurses regardless of unit experience.

Conclusions:
Increasing nursing knowledge and professional competence in delivering and documenting stroke education that is compliant with national guidelines may lead to inpatient nurses providing higher quality stroke education. Understanding risk factors for a second stroke may improve long-term health outcomes for stroke patients and potentially decrease the incidence of secondary stroke. Next steps for this initiative are integration of the education developed in this project into the new RN orientation for the units involved as well as inclusion of the information in ongoing continuing nursing education classes conducted by the clinical site.
Abstract TP484: Does Near Real Time Tracking of Treatment Process Performance via a Large-Scale Stroke Data Repository With Enhanced Data Visualization and Analytics Improve Treatment Times?
Authors: Rhoten Jeremy B , Asimos Andrew W , Karamchandani Rahul R , Raheem Enayetur , Strong Dale
Published: January 2019

Introduction:
To facilitate process improvement and outcomes tracking, our large, integrated healthcare system created an extensive database within REDCap which interfaces with Power BI (Microsoft). Monitored metrics include pre-hospital, Code Stroke process, advanced imaging, treatment, and outcome data fields. Data are entered via manual abstraction, but automated daily updates of the data visualization and analytics enables reviewing of individual case data and aggregate standardized reports within Power BI. The advanced visualization allows the stroke team to facilitate process improvement in near real time. Our team looked to analyze the statistical impact on stroke metrics after implementation of the real time data review process.

Methods:
We dichotomized data into patients initially presenting to our Comprehensive Stroke Center (CSC), versus those transferred to our CSC for potential mechanical thrombectomy. We then compared data for the 5-months before and 5-months after implementation of our advanced analytics.

Results:

Conclusions:
In patients that arrivied directly to our CSC, we saw a statistical difference in patients Last Known Well to Door, Door to IVtPA Bolus, Door to Groin Puncture, and a 2% increase in mRS of 0-2 without statistical difference. In patients that were transferred to our CSC, we saw no statistical differences in any measure, but an overall decrease in Door to Treatment times and a 10% increase in mRS of 0-2. The expansion of Code Stroke window to include patients within 24 hours happened shortly after the comparison group started, leading to a significant increase in Last Known Well to Door for patients presenting to our CSC.
Abstract TP490: Analysis of Cerebral Hemodynamics and Interaction of 0.1-hz Oscillations of Hemodynamic Parameters in Postural Orthostatic Tachycardia Syndrome
Authors: Shin Dong Hoon , Song Soowha
Published: January 2019

Background:
POTS is defined as heart rate increase of more than 30 beats within the first minutes of standing upright. The aim of this study was to analyze causal connectivity among cerebral hemodynamic changes in head-up tilt test (HUT) of POTS using TCD and Finometer between normal and POTS.

Methods:
Normal (n=20) and POTS (n=20) were enrolled to monitor the beat-to-beat arterial blood pressure (ABP) using Finometer and Cerebral blood flow velocity (CBFV) in right MCA using TCD. Subjects rested in supine position for 5 min and subjects were abruptly positioned at 80
o
from horizontal on a tilt table. Beat-to-Beat ABP pulse intervals (HR) were calculated using foot points of each pulse. We divided HUT into early tilt stage (ETS) and late tilt stage (LTS). We analyzed several variables including ABP, HR, systolic CBFV, critical closing pressure (CrCP) between normal and POTS. To analyze effects of intrinsic spontaneous oscillations known as ‘Mayer waves’, in ABP, CBFV, and HR, the frequency component from 0.06Hz to 0.15Hz was extracted using FIR filter. Then Granger causality was calculated to analyze the changes of causal connectivity of each signal by HUT effects.

Results:
CrCP during HUT in POTS was significantly larger than normal. Compared with normal, POTS showed significantly increased causal flow of ABP◊HR and HR◊CBFV during ETS and causal flow of CBFV◊ABP during LTS. In paired t-test of state change from supine to ETS, while causal flow of ABP◊CBFV in normal was significantly increased during supine, causal flow of ABP◊CBFV and ABP◊HR in POTS were significantly increased during ETS. In paired t-test of state change from ETS to LTS, while causal flow of HR◊CBFV in normal was significantly increased during ETS, causal flow of ABP◊CBFV and HR◊CBFV in POTS were significantly decreased during LTS. In POTS, causal density of HR◊BP during spine was significantly increased and causal density of HR◊CBFV and BP◊CBFV were significantly decreased during LTS.

Discussion:
This study showed that increased CrCP during HUT is related with increased coupling of 0.1-Hz oscillations from ABP to HR and from HR to CBFV in POTS. Increased CrCP during HUT may cause the excessive blood pooling and the low effective circulating volume in the central vasculature and can explain symptom of POTS.
Abstract TP498: Application of F.A.S.T Algorithm to Pediatric Stroke: A Comprehensive Stroke Center Retrospective Analysis
Authors: Grewal Parneet , Qaiser Sharoon , Pradeep Swati , Lightner Donita , Goldstein Larry B
Published: January 2019

Objective:
To assess the demographic characteristics and presenting symptoms of a cohort of children who were admitted with ischemic stroke and develop a modification of an adult stroke recognition tool that would applicable to pediatric population.

Method:
We conducted a retrospective medical record review of all children aged 1 month to 18 years with radiologically confirmed ischemic stroke who were admitted to the University of Kentucky between January 2013-December 2017. Age, sex, race, presenting symptoms, stroke etiology and discharge disposition were recorded. The FAST mnemonic (Face, Arm, Speech) was applied to all patients.

Results:
There were 38 children with ischemic stroke (89% Caucasian, 73% boys). The strokes were most commonly associated with traumatic (28%) followed by intracranial infection (21%). FAST accurately identified 21 of stroke patients (61%), but only 35.7% of the children < 3 years of age. The addition of new onset seizures to FAST (FAST-S) increased overall sensitivity to 78.9% and to 100% in the 1month - 3 years’ age group.

Conclusions:
Unlike adults, the most common causes of pediatric stroke in our cohort were trauma and infection. FAST is not sensitive in the pediatric population, particularly in children <3-years old. The addition of new onset seizures in children to FAST improves stroke identification.
Abstract TP518: Ethnic Differences in Poor Metabolizer Alleles of 12 Pharmacogenomic Actionable Genes in Asian Indians
Authors: Sanghera Dharambir S , Bejar Cynthia ,   Asian Indian Diabetic Heart Study Investigators
Published: January 2019

Introduction:
Diversity in drug response related to cardiovascular and other diseases is attributed to both genetic and non-genetic factors. However, there is a paucity of genetic information across ethnically and genetically diverse populations. Here, we have analyzed 20 SNPs from 12 pharmacogenomics genes in Punjabi Sikhs of Asian Indian origin (N= 1,616), as part of the Sikh Diabetes Study (SDS)/Asian Indian Diabetic Heart Study (AIDHS).

Methods:
Samples were genotyped using the Human 660W Quad Bead Chip panel (Illumina, Valencia, CA). We compared the allelic associations with poor metabolism (PM) phenotype across other HapMap populations.

Results:
Indians had a significantly higher frequency of CYP2C9*3 (12% SDS, 13% GIH (Gujarati Indians) vs. 5% in Europeans (CEU) (p
genotype
= 0.008) and ‘T’ allele of CYP4F2 (36%) SDS, (43%) GIH vs. (21%) in CEU (p
genotype
=7.8x10
-7
); both associated with a higher risk of bleeding with warfarin. The PM phenotype of the CYP1A2*1F allele for slow metabolism of caffeine and carcinogens was significantly higher in Indians (SDS 43%, GIH 51%) compared to CEU 29% (p
genotype
=0.01). While the frequency of ‘T’ risk allele MTHFR (C677T) was significantly lower in Indians compared to Europeans (0.19 SDS, 0.16 GIH vs. 0.31 CEU), the low activity ‘C’ allele of MTHFR was strikingly higher in SDS (44%) compared to GIH (39%) and CEU (34%) (p
genotype
=4.9x10
-3
). These variants in MTHFR affect the metabolism of cholesterol-lowering (statins), 5-fluorouracil, and methotrexate-based cancer drugs.

Conclusion:
This is a first large study reporting a significant ethnic difference in the frequency of PM phenotype in Indian Sikhs compared to other global populations. Our findings underscore the need for establishing a global benchmark by conducting pre-emptive genotyping in drug metabolizing genes before beginning therapeutic intervention.
Abstract TP52: Comparison Early Neuroimaging Findings in Patients With Basilar Artery Occlusion Who Received Endovascular Treatment
Authors: Kwak Jae Hyuk , Lee Hyo Min
Published: January 2019

Introduction:
The natural history of acute ischemic stroke due to basilar artery occlusion is poor. Several early neuroimaging derived predictors of outcome have been proposed in posterior circulation infarction. Early neuroimaging predictors in posterior circulation infarction may be primarily subdivided into those that evaluate for early ischemic changes (posterior circulation acute stroke prognosis early CT score(pc-ASPECTS) or pc-ASPECTS score on DWI), collateral flow(Collateral score(CS)), thrombus location and burden(Basilar artery on computed tomography angiography (BATMAN) score).

Method:
We retrospective acquired data for 52 patients with acute cerebral infarction due to basilar artery occlusion who received endovascular treatment at multicenter registry. All patient underwent brain CTA and diffusion MRI before endovascular treatment. We measured pc-ASPECTS, pc-ASPECTS score on DWI, CS and BATMAN score in all patients. We compared which early neuroimaging protector is most correlated with the modified Rankin scale at 3 months.

Result:
In receiver operating characteristic (ROC) analysis, pc-ASPECTS had an area under ROC curve of 0.568 (95% confidence interval (CI), 0.41-0.72: P=0.402). Pc-ASPECTS score on DWI had an area under ROC curve of 0.737 (95% confidence interval (CI), 0.61-0.87: P=0.004). CS had an area under ROC curve of 0.589(95% confidence interval (CI), 0.43-0.74: P=0.273). BATMAN score had an area under ROC curve of 0.676(95% confidence interval (CI), 0.53-0.82: P=0.30).

Conclusion:
Pc-ASPECTS score on DWI and BATMAN score were significantly associated with clinical outcome among early neuroimaging findings. Pc-ASPECTS score on DWI is the best predictor of prognosis in basilar artery occlusion patients.
Abstract TP522: Clopidogrel Use and Smoking Cessation Result in Lower Coated-Platelet Levels After Stroke
Authors: Kirkpatrick Angelia , Vincent Andrea , Dale George , Prodan Calin
Published: January 2019

Introduction:
Coated-platelets are a subset of highly procoagulant platelets observed upon dual-agonist stimulation with collagen and thrombin. Coated-platelet levels are elevated in patients with ischemic stroke and associated with stroke recurrence. Cross-sectional studies in controls showed that smoking was associated with higher coated-platelet levels whereas chronic use of serotonin reuptake inhibitors (SSRIs), statins or aspirin was associated with lower coated-platelet levels. Limited data in patients with coronary artery disease have shown an inhibitory effect on coated-platelet potential at 24 hours following the administration of a 300 mg single dose of clopidogrel. We now investigate if initiation of pertinent medications and smoking cessation result in long-term changes in coated-platelet levels following ischemic stroke.

Methods:
Coated-platelet levels, reported as percent of cells converted to coated-platelets, were measured in 87 consecutive patients with non-lacunar stroke at baseline and repeated at 90 days. Repeated-measure ANOVA was used to determine if initiation of treatment with SSRIs, statins, clopidogrel, aspirin, oral anticoagulants or smoking cessation impacted changes in coated-platelet levels.

Results:
Initiation of treatment with clopidogrel (absolute decrease = 8.9%, relative decrease = 20.9%, p = 0.0001, partial η
2
= 0.17) and smoking cessation (absolute decrease = 8%, relative decrease = 18.2%, p = 0.014, partial η
2
= 0.10) resulted in decreased coated-platelets levels at 90 days as compared to baseline. Use of SSRIs, statins, aspirin or oral anticoagulants did not result in significant changes.

Conclusions:
Clopidogrel use and smoking cessation attenuate coated-platelet potential at 90 days after ischemic stroke. These data suggest that both pharmacological agents and behavioral modification result in long-term modulation of coated-platelet production likely through inhibition of the P2Y12 receptor and inflammatory pathways. Future studies are needed to better define mechanisms involved.
Abstract TP525: Pharmacological Smoking Cessation Therapies for Patients With Cerebrovascular Disease: A Systematic Review
Authors: Parikh Neal S , Salehi Omran Setareh , Elkind Mitchell S , Willey Joshua
Published: January 2019

Introduction:
Recent studies demonstrated the efficacy and safety of pharmacological smoking cessation therapy for patients with heart disease. Similar data are lacking for patients with cerebrovascular disease, who pose unique safety concerns such as seizure and neuropsychiatric risks. We systematically reviewed the evidence for the efficacy and safety of pharmacological cessation therapies in patients with cerebrovascular disease.

Methods:
We searched the Medline, Cochrane, and Clinicaltrials.gov databases to identify randomized controlled trials (RCT) and observational studies comparing varenicline, bupropion, or nicotine replacement therapy (NRT) versus non-pharmacological cessation therapies in patients with ischemic and hemorrhagic stroke. We included studies that reported rates of smoking cessation, worsening or recurrent cerebrovascular disease, seizures, or neuropsychiatric events. The quality of evidence was assessed using a structured framework. We adhered to systematic review guidelines.

Results:
We identified 2 RCTs and 6 observational studies; 3 included ischemic stroke and transient ischemic attack, 2 subarachnoid hemorrhage (SAH), and 3 did not specify. There was substantial heterogeneity of the timing and nature of interventions, precluding meta-analysis. Pharmacological therapies were often co-administered with intensive behavioral interventions. Efficacy was assessed in 4 studies; cessation rates ranged from 33% to 66% with pharmacological therapy versus 15% to 47% without. Results were not statistically significant in any individual study. Safety data in ischemic stroke were scarce. Among patients with SAH, patients who received NRT in 1 study had a higher incidence of seizures (9% vs 2%; P=0.024) and delirium (19% vs 7%; P=0.006), but rates of vasospasm were not statistically different in 3 studies.

Conclusions:
There were insufficient high-quality data to conclusively assess the efficacy and safety of pharmacological smoking cessation therapies in patients with cerebrovascular disease. Combined with behavioral interventions, these therapies resulted in numerically higher cessation rates. The safety of these agents, particularly with respect to seizures and delirium, warrants further study.
Abstract TP536: Can Baseline Glomerular Filtration Rate Predict Outcomes in Hemorrhagic Stroke Patients?
Authors: Saeed Omar , Malkoff Mark , Alexandrov Andrie , Ishfaq Fawad , Pandhi Abhi , Singh Savdeep , Qureshi Adnan I
Published: January 2019

Background:
Chronic kidney disease with reduced glomerular filtration rates (GFR) has been described as a risk factor for hemorrhagic stroke. The goal of this analysis was to determine if baseline GFR can predict long-term outcomes and/or incidence of adverse events in those patients who presented with hemorrhagic stroke.

Methods:
Retrospective analysis was done using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine the effect of baseline GFR on occurrence of adverse events, mortality and death and disability at 90 days. GFR were calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation using specified race, sex and serum creatinine in mg/dl from the National Institute of Diabetes and Digestive and Kidney Disease for estimation in patients age 18 and over. We compared demographic and clinical characteristics of subjects dichotomized into none/mild CKD (GFR ≥60 mL/min/1.73m
2
) versus those who had moderate/severe CKD (GFR ≤59 mL/min/1.73m
2
). We performed a multivariate analysis using cox proportional hazard model after adjusting for confounders.

Results:
Of the total 1000 participants in ATACH-2 trial 562 had baseline creatinine levels out of which there were 122 (21.7%) who had baseline GFR of ≤59 mL/min/1.73m
2
defined as moderate/sever GFR with mean age 65.7 SD± 13.6 and 59.8% were males. Those with moderate to severe GFR had significantly higher rates of previous stroke (26.2% vs 13.6%), congestive heart failure (8.3% vs 1.8%), previous ischemic heart disease (13.1% vs 1.6%), hypertension (88.5% vs 75.2%), hyperlipidemia (37.7% vs 20.7%), and diabetes mellitus (32% vs 14.3%). In the multivariate analysis after adjusting for age, Asian race, white race, hypertension, diabetes, hyperlipidemia and smoking those with moderate to severe GFR had significantly higher risk of death (HR 18.1, 95% confidence interval [CI] 1.3- 278.6; p-vale .033) and unfavorable outcome defined by a 90 day mRS score of 4-6 (HR 1.4, 95% CI 1.1 -1.9; p-value .015).The wide confidence interval in death could be due to small sample size.

Conclusion:
Patients with moderate to severe GFR at baseline appear to have higher rates of mortality and death and disability with a mRS score of 4-6 at 90 days.
Abstract TP541: CT Angiography Leptomeningeal Collateral Assessment for Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage
Authors: Colip Charles , Wo Sean , Urdaneta-Moncada Alfonso , Hippe Daniel , Watase Hiroko , Kelly Cory , Levitt Michael , Mossa-Basha Mahmud
Published: January 2019

Introduction:
Although leptomeningeal collaterals in acute large vessel occlusion have been well studied with respect to core infarct volume and risk of hemorrhagic conversion, their association with vasospasm in the setting of subarachnoid hemorrhage is less clear. Our purpose is to investigate the utility of leptomeningeal collateral scoring on CTA of patients presenting with aneurysmal subarachnoid hemorrhage (aSAH).

Methods:
IRB-approved retrospective review of 122 consecutive patients with angiographic vasospasm after surgical or endovascular repair of ruptured intracranial aneurysm. A 5-point grading scale was adapted from Christoforidis et al. to compare leptomeningeal collateral scores on CTA with digital subtraction agiography (DSA) at presentation. An independent chart review was performed to correlate imaging with clinical markers of symptomatic vasospasm and delayed cerebral ischemia.

Results:
Of the 122 initial patients with vasospasm, 16 demonstrated unilateral high-grade M1 stenosis in the absence of a second ipsilateral large vessel stenosis, 11 of which (68.8%) developed cerebral infarction secondary to vasospasm. Leptomeningeal collateral scoring on CTA at presentation agreed with DSA scores in half of patients (n=8), underestimated collaterals by 1 point in 7 patients, and overestimated their presence by 1 point in a single case.

Conclusion:
Characterization of leptomeningeal collaterals in patients with aSAH may better predict subsequent vasospasm and cerebral ischemia. Our initial findings in cases of isolated severe M1 vasospasm highlight the potential value of collateral scoring on CTA at presentation. Collateral scoring on CTA correlates with DSA in half of cases, however further work is indicated to elucidate the technical factors contributing to 1-point underestimation in the other half cases. Christoforidis, G.A., et al.,
Predictors of hemorrhage following intra-arterial thrombolysis for acute ischemic stroke: the role of pial collateral formation.
AJNR Am J Neuroradiol, 2009.
30
(1): p. 165-70.