bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP22: A Scoring System Based on Age and DWI Volume Predicts Poor Functional Outcome Following Endovascular Treatment for Acute Ischemic Stroke
Authors: Liggins John , Mishra Nishant K , Wheeler Hayley M , Straka Matus , Kemp Stephanie , Mlynash Michael , Bammer Roland , Albers Gregory W , Lansberg Maarten G ,   The DEFUSE 2 investigators
Published: July 2021

Background:
The Houston IAT (HIAT) score predicts poor outcome following endovascular stroke therapy based on clinical variables (age, serum glucose, and NIHSS score). We aimed to validate the HIAT score in an independent cohort of patients treated with endovascular therapy (DEFUSE 2) and determine if prediction of poor outcome could be improved by including neuroimaging variables in the prediction score.

Methods:
Patients enrolled in the DEFUSE 2 study had a clinical diagnosis of acute ischemic stroke and underwent MRI prior to endovascular treatment. Poor functional outcome was defined as a modified Rankin Scale score of 4 to 6 at day 90. The relationship between baseline clinical and neuroimaging variables and poor functional outcome was assessed using univariate and multivariate logistic regression. Statistically significant variables in the multivariate model were used to create a new scoring system. We evaluated the new scoring system and the HIAT score using ROC analysis.

Results:
One hundred and ten patients were included in the analysis; forty-two patients had a poor functional outcome. Validation of the HIAT score demonstrated similar ROC properties in the DEFUSE 2 cohort (AUC=0.69) compared to the Houston derivation cohort (AUC=0.73). In DEFUSE 2, age (p=0.001), baseline DWI volume (p=0.09), baseline NIHSS score (p=0.03) and hypertension (p=0.003) were associated with poor functional outcome in univariate analysis. In multivariate analysis, age (p<0.001) and baseline DWI volume (p=0.03) were independent predictors of poor functional outcome. Based on this we developed a new scoring system with a maximum of 3 points awarded for age (0 points, < 55; 1 point, 56-69; 2 points, 70-79; 3 points, ≥ 80) and a maximum of 1 point awarded for baseline DWI volume (0 points, volume ≤ 15 cc; 1 point, volume >15 cc). The percentage of patients with poor functional outcomes increased with the number of points awarded (0% poor outcomes in patients with 0 points, 25% with 1 point, 30% with 2 points, 75% with 3 points, and 89% with 4 points). The AUC for the new scoring system was 0.82.

Conclusion:
The new scoring system that incorporates baseline DWI volume and age predicts poor outcome more accurately than a scoring system based on clinical variables alone.
Abstract WP223: Chronic Atherosclerotic Moyamoya Syndrome of the Middle Cerebral Artery: A Hemodynamic Study with CT Perfusion
Authors: Jo Kwang Deog , Kim Woo Sang , Bae Moon Jung , Choi Myung Hee , Han Jeesue , Jung Jin Mu , Yang Hyun Ju
Published: July 2021

Background:
Moyamoya vessels, an abnormal vascular collateral network at the base of the brain, are associated with moyamoya disease and secondary moyamoya syndrome. Several studies have suggested that ischemic symptoms in patients with moyamoya vessels are most closely related to hemodynamic impairment. However, few studies have evaluated cerebral perfusion state in secondary atherosclerotic moyamoya syndrome. The purpose of our study was to evaluate cerebral hemodynamics measured by acetazolamide CT perfusion (CTP) imaging in patients with moyamoya syndrome associated with symptomatic atherosclerotic occlusion of the unilateral middle cerebral artery (MCA).

Methods:
Multidetector helical CTP imaging was performed in 14 patients (mean age, 54.4 years), who were clinically diagnosed to have moyamoya syndrome associated with unilateral atherosclerotic steno-occlusion of the proximal MCA. All patient underwent cerebral angiography and CTP imaging. Hemodynamic quantitative parameters of regional cerebral blood flow (rCBF), cerebral blood volume (rCBV), and mean transit time (rMTT) were measured in the anterior cerebral artery (ACA), MCA, and posterior cerebral artery (PCA) territories of both hemispheres separately. The Cerebral vascular reserve (CVR) capacity was measured using acetazolamide.

Results:
Mean resting rCBF in the ipsilesional ACA and MCA territories were significantly lower than in the contralateral territories (P<0.05). After acetazolamide infusion, the rCBF was significantly increased in the ipsilesional ACA, PCA, and all three contralateral territories (P<0.05) and rCBV was significantly increased in the all ipsilesional and contralateral territories (P<0.05). The CVR capacity changes were not significantly different between ipsilesional and contralateral territories.

Conclusions:
These findings suggest that the affected MCA territory has decreased perfusion with poor vasomotor reactivity despite abundant collateral circulation through the basal moyamoya vessels in patients with atherosclerotic moyamoya syndrome.
Abstract WP230: The Yield of Echocardiography in Cancer Patients with Suspected Cardioembolic Stroke
Authors: Cheng Natalie T , Singer Samuel , Merkler Alexander , Stone Jacqueline B , Kamel Hooman , DeAngelis Lisa M , Navi Babak B
Published: July 2021

Background:
Autopsy studies demonstrate that cardioembolism from nonbacterial thrombotic endocarditis (NBTE) is a common cause of stroke in patients with cancer. Echocardiography is often used to clinically diagnose NBTE, but it has unknown yield for NBTE lesions, which are typically small and difficult to detect.

Methods:
We identified all patients with active cancer admitted to Memorial Sloan-Kettering Hospital from 2008 to 2010 with acute ischemic stroke who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data and classified patients as having suspected cardioembolic (CE) strokes if brain MRI showed embolic-appearing infarcts in more than one vascular territory. They also reviewed TTE and TEE reports and adjudicated whether these studies revealed a definite or possible source of stroke. Definite sources included complex aortic arch atheroma, valve vegetation, left atrial or ventricular thrombus, patent foramen ovale (PFO) with documented venous thromboembolism (VTE), severe cardiomyopathy, or cardiac tumor. Possible sources consisted of PFO without VTE, atrial septal aneurysm, dyskinetic left ventricular segment, spontaneous echo contrast, and simple aortic arch atheroma. NBTE was diagnosed if valve vegetations were seen on echocardiography, blood cultures were negative, and clinical signs of infection were absent.

Results:
Among 119 patients with cancer and ischemic stroke (mean age 66 [SD 13], 51% men), 99 (83%) had TTE and 16 (13%) had TEE. TTE revealed a definite source in 3 (3%) patients and a possible source in 15 (15%). Conversely, TEE revealed a definite source in 6 (38%) patients and a possible source in 5 (31%). No vegetations were seen on TTE, but 4 were discovered on TEE, all from NBTE. In 42 of 52 patients with suspected CE stroke who underwent TTE, 3 (7%) had a definite source and 8 (19%) a possible source. Eleven of these patients also underwent TEE, which demonstrated a definite or possible source in 9 (81%).

Conclusions:
The yield of TTE for detecting NBTE and other cardiac sources of stroke in patients with cancer is poor, but TEE may be helpful in targeted patients.
Abstract WP242: A Drill Down Analysis of Door-to-Needle Time of Acute Ischemic Stroke Patients Treated with Intravenous Tissue Plasminogen Activator
Authors: Lum Marija , Schrock Jon
Published: July 2021

Background:
Target stroke guidelines recommend a door-to-needle time (DNT) ≤60 minutes for acute ischemic stroke (AIS) patients treated with tissue plasminogen activator (tPA). Research has shown that <30% of patients achieve this goal. It is unclear how the timing of chest radiography (CXR) and electrocardiography (EKG) affect DNT. We studied all steps involved in the evaluation and treatment of AIS with IV tPA to look for causes of delay.

Methods:
A retrospective review of all AIS patients treated in the ED with IV tPA over a four year period was performed. Transferred patients were excluded. Times comparing intervals from door to head CT, CT result, EKG, CXR, and IV tPA treatment, were evaluated. Demographic data and length of symptom onset were recorded. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and χ
2
testing was used as appropriate.

Results:
A total of 79 AIS patients met inclusion criteria, with 22 (28%) receiving IV tPA ≤60 minutes. Treatment with tPA in ≤60 minutes was significantly greater if symptom onset was >90 minutes (p<0.05) and if the EKG was done after the head CT (p<0.05). There was a change in median CT times with those who received EKG before CT and those who did not, 23 min (15-36 min) and 17 min (10-24min), respectively. Patients who received a CXR before CT had a median CT time of 32 min (21-38min) compared to 19 min (13-27min) for patients who did not. Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 7 (9%) patients. Post-tPA hemorrhage occurred in 13 (16%) patients. Eight (10%) patients expired.

Conclusion:
Non-critical studies performed prior to head CT increase DNT. An EKG performed before the head CT is completed increased CT time by 6 minutes and a CXR obtained before the head CT increased CT time by 13 minutes. Physician urgency is also a critical factor in DNT and is diminished in patients who arrive soon after symptom onset. DNT ≤60 minutes for AIS patients are affected by the level of urgency and order of diagnostic studies. Current primary stroke center recommendations of an EKG and CXR within 45 minutes may result in delayed treatment if these studies are performed before the head CT.
Abstract WP252: Reduction in Stroke Readmission Rates After Implementing an Emergency Department-based Transient Ischemic Attack Observation Unit
Authors: Fayas Lori , Polum Kathy , Stanko Heather
Published: July 2021

Background and Purpose
—Diagnosis and treatment of transient ischemic attacks (TIAs) is often delayed by lack of access to immediate comprehensive evaluation of the underlying etiology. Early initiation of treatment can reduce the risk of early recurrent stroke by up to 80%. Up to 40% of people who have experienced a TIA will go on to have a stroke. The purpose of this review was to determine the efficacy of an Emergency Department (ED)-based TIA observation unit using a standardized TIA protocol designed to provide rapid evaluation and treatment of patients presenting with TIA in reducing the rates of readmission with stroke to a community-based hospital.

Methods
—We did a retrospective chart review of all patients discharged from Bellin Hospital with a diagnosis of stroke before implementing a standardized TIA protocol in our ED-based TIA observation unit (July to December 2010) and after implementation of the TIA observation unit (November 2011 to April 2012). We identified the patients in these cohorts who had previously been evaluated in the ED with signs or symptoms of stroke in the 6 months prior to admission and compared their stroke readmission rates. Patients who received evaluation through the TIA observation unit from November 2011 to April 2012 were monitored for readmission for stroke in the 6 months after evaluation.

Results
—Prior to use of the TIA observation unit, 7 of 51 (13.7%) patients discharged with a diagnosis of stroke had been seen in the ED in the previous 6 months with stroke-like symptoms. After implementation of the TIA observation unit, 7 of 119 (5.9%) patients discharged with a diagnosis of stroke had been seen in the ED, a 57.1% reduction in stroke readmission at 6 months. Of these, 4 (57.1%) had not completed the work-up during their previous ED visit. 122 patients underwent evaluation using the TIA observation unit. Of these, only 3 (2.5%) patients were readmitted for stroke in the next 6 months. 16 of these 122 (13.1%) patients were diagnosed with stroke during their TIA work-up.

Conclusions
—Rapid evaluation and treatment of TIA through an ED-based TIA observation unit substantially reduces the risk of readmission for stroke.
Abstract WP273: Reversal of Dabigatran’s Anticoagulant Activity in the Monkey by a Specific Antidote and Pharmacokinetic and Pharmacodynamic Modeling
Authors: Toth Joshuaine , Gan Guanfa , Van Ryn Joanne , Dursema Holly , Isler Jennifer , Coble Kelly , Burke John , Lalovic Bojan , Olson Stephen
Published: July 2021

The objective of this study is to determine pharmacokinetics (PK) and pharmacodynamics (PD) of dabigatran and its antidote (a humanized Fab against dabigatran) in the monkey and to develop a combined mechanistic mathematical model to describe the data. Rhesus monkeys (n = 2/group) received either 12 mg/kg/day of dabigatran etexilate (DE) or vehicle orally on Days 1-4, 15-18 and 29-32 with a single IV dose of the antidote at 30, 90 and 175 mg/kg administered 90 minutes after DE on Days 4, 18 and 32. PK parameters of the antidote and sum dabigatran (dabigatran plus its glucuronides) were determined after measurements of plasma concentrations. Coagulation activity was measured using a diluted thrombin time assay. The PK of the antidote were not affected by dabigatran. Clearance of the antidote was low (0.87 mL/min/kg) and steady-state volume of distribution was small (0.06 L/kg), indicating that the antidote was mostly restricted to plasma. The plasma profile of the antidote was bi-phasic with a short initial phase t
1/2
of 0.4 hour (h) and a terminal phase t
1/2
of 4.3 h. Complete reversal of dabigatran’s anticoagulant activity was observed immediately after antidote dosing at all 3 dose levels as measured by the diluted thrombin time assay, and the degree to which this reversal effect was maintained over an extended period (24 h) was dose-dependent. A mechanistic ordinary differential equation model, based on the mass action kinetics for describing the distribution, binding and elimination of dabigatran and its antidote, was developed by combining the PK models for dabigatran and the antidote and adding the binding interaction (1:1 stoichiometry) between the two compounds. The combined PK/PD model of dabigatran and antidote was able to describe the in vivo PK/PD data observed in monkeys. In conclusion, the antidote successfully reversed the anticoagulant activity of dabigatran in the monkey in a dose-dependent manner, and our combined mathematical model accurately describes monkey PK/PD data of sum dabigatran and its antidote. Insights gained from this model will be used to guide model development for clinical trials.
Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book
Authors: Wisco Dolora , UCHINO KEN , CHENG CHING ESTEBAN , Alam Shazia , MAN SHUMEI , GEORGE PRAVIN , NEWEY CHRIS , Hussain M Shazam
Published: July 2021

INTRODUCTION:
In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion.

Objective:
To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT.

Methods:
From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0.

Result:
151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005).

Discussion:
In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.
Abstract WP293: Baseline Perihematomal Edema is Greater in the Presence of a CTA Spot Sign but Does Not Predict Hematoma Expansion Independent of ICH Volume
Authors: Rodriguez-Luna David , Stewart Teri , Subramaniam Suresh , Dowlatshahi Dar , Kosior Jayme C , Aviv Richard I , Molina Carlos A , Silva Blas Yolanda , Dzialowski Imanuel , Lum Cheemun , Czlonkowska Anna , Boulanger Jean-Martin , Kase Carlos S , Gubitz Gord , Bhatia Rohit , Padma Vasantha , Roy Jayanta , Hill Michael D , Demchuk Andrew M ,   PREDICT/Sunnybrook ICH CTA study group
Published: July 2021

Background:
Similarly to intracerebral hemorrhage (ICH), perihematomal edema (PHE) increases with time from onset. A small degree of PHE relative to ICH may suggest a very early timepoint from onset or actively bleeding ICH and therefore predict a higher likelihood of hematoma expansion (HE). The relationship between PHE, ICH and HE has not however been established. Therefore, we aimed to investigate the link between PHE and ICH by time and their relationship with the CTA spot sign and HE.

Methods:
The PREDICT study was a multicentric, prospective, observational cohort study of ICH patients <6 hours. All study cohort subjects with available baseline CT scan images (n=377) were included in this analysis. Volumes and diameters of total lesion, ICH and PHE were measured systematically by two blinded investigators, respectively. Diameter measurements were taken in the axial CT slice with the largest ICH area. Significant HE was defined as ICH enlargement >33% or >6mL at 24 hours.

Results:
Correlation between volume and diameter measurements was strong for total lesion (r=0.9; p<0.001) and ICH (r=0.88; p<0.001), but moderate for PHE (r=0.43; p<0.001). PHE represented a half of the total lesion volume at baseline (Table). PHE volume and diameter were not related to time from onset to baseline CT, although PHE/ICH diameter (p=0.017) and volume (p=0.061) ratios were higher the later the baseline CT scan was performed. Spot-sign patients (29.7%) had more baseline PHE, ICH and total lesion than spot-negative patients (Table). HE analysis was limited to 322 patients with follow-up CT before rFVIIa or surgical intervention. HE patients (32%) presented with higher PHE, ICH and total lesion volumes (Table). Baseline PHE diameter and volume ratios however did not predict subsequent HE.

Conclusion:
Edema represents about half of total lesion volume in acute ICH. Edema and ICH are larger in the presence of a CTA spot sign. Edema alone does not predict subsequent hematoma expansion.
Abstract WP295: Acute Blood Pressure Reduction in Intracerebral Hemorrhage Patients Does Not Increase Hypoperfused Tissue Volume: a CT Perfusion Threshold Study
Authors: Gould Bronwen , McCourt Rebecca , Hill Michael D , Asdaghi Negar , Dowlatshahi Dariush , Jeerakathil Thomas , Coutts Shelagh B , Demchuk Andrew M , Shuaib Ashfaq , Emery Derek , Butcher Ken S
Published: July 2021

Background:
The Intracerebral Hemorrhage Acutely Decreasing Arterial Pressure Trial (ICH ADAPT) demonstrated that aggressive blood pressure (BP) reduction does not affect mean perihematoma cerebral blood flow (CBF). It remains unknown if portions of the perihematoma region or watershed vascular territories (borderzones, BZs) reach ischemic thresholds after BP reduction. We tested the hypothesis that aggressive BP reduction was associated with an increased volume of critically hypoperfused tissue in ICH ADAPT patients.

Methods:
ICH patients were randomized to a target systolic BP (SBP) of <150 or <180 mmHg and imaged with CT perfusion (CTP) 2h later. A 1cm perihematoma region, and ipsilateral and contralateral internal and external BZs were outlined. The volume of tissue below CBF thresholds for ischemia (<18ml/100g/min) and infarction (<12ml/100g/min) was calculated as a percentage of the total volume of each region of interest.

Results:
ICH patients (n=73) were randomized a median (IQR) of 7.8 (13.3) h from onset and imaged with CTP 2.3 (1.0) h later. Acute hematoma volume was 17.8 (27.1) ml and mean SBP was 183±22 mmHg. At the time of CTP, SBP was lower in the <150 mmHg group (n=37, 140±18 mmHg) than the <180 mmHg group (n=36, 162±12 mmHg, P<0.001). Mean CBF in the perihematoma region did not differ between groups (<150 mmHg: 38.9±13.0 vs. <180 mmHg: 38.5±10.9 ml/100g/min, P=0.86). BP treatment did not affect the percentage of perihematoma tissue with CBF <18 (17.5±15.4 (<150 group) vs. 16.5±14.3% (<180 group), P=0.82) or <12 ml/100g/min (7.0±7.2 vs. 6.6±7.6%, P=0.93). Similar results were found in all BZs. Linear regression revealed no relationship between low SBP load (the fraction of time between randomization and CTP with SBP <150mmHg) and the percentage of perihematoma tissue with CBF <18 (β=3.62, [-6.86, 14.10]) or <12 ml/100g/min (β=1.89, [-3.30, 7.08]). There was no relationship between low SBP load and percentage of hypoperfused tissue in any BZ. Perfusion threshold analysis of time domain parameters and cerebral blood volume yielded similar results.

Conclusion:
BP reduction does not increase the volume of hypoperfused tissue, at any threshold examined, in the perihematoma region or any BZ. These data support the safety of early BP reduction in ICH.
Abstract WP298: Matrix Metalloproteinases Are Involved In The Regulation Of Angiogenesis After Intracerebral Hemorrhage
Authors: Liu Qi-Ting , Cui Han-Jin , Luo Jie-Kun , Lin Yuan , TANG TAO
Published: July 2021

Background and purpose:
Intracerebral hemorrhage (ICH) is one of the most devastating subtypes of stroke. And our previous work has demonstrated that ICH induces angiogenesis, accompanied by up-regulation of pro-angiogenic factors. Matrix metalloproteinases (MMPs) can cause blood-brain barrier dysfunction by degrading the extracellular cellular matrix (ECM) around the vessels after ICH, but opening a way for the prolonging newborn vessels is a key step for their functional structure, therefore, the purpose of the study is to investigate whether MMPs are involved in the process of angiogenesis after ICH.

Methods:
Thirty Kunming mice were randomly divided into sham group, ICH group and doxycycline (DOX)-treated group. And then 5 mice were randomly selected for Western Blot to detect the expression of MMP9, and the other five for the immunohistochemistry to detect vWF. ICH model was induced by injection collagenase type VII into right globus pallidus stereotaxically, and DOX, a broad-spectrum MMP inhibitor, was injected by intraperitoneally at 7 days after ICH induction. Neurological severity score (NSS), corner turn test and foot-fault test were used to investigate the neurological function. And vWF-positive vessels were counted around the hematoma.

Results:
At 7 days, there is no difference between the two ICH-induced groups in NSS, corner turn test, foot-fault test; while at 14 days, the NSS in ICH group is significantly lower than that of DOX-treated group (
P
<0.05), and the times for right-turn and foot-fault in ICH group are notably fewer than those of DOX-treated group (
P
<0.05); At 14d, the number of vWF-postive microvessel in ICH group was significantly larger than that of DOX-treated group (
P
<0.01), and Western Blot revealed that DOX decreased MMP9 expression remarkably(
P
<0.01).

Conclusion:
Matrix metalloproteinases were involved in the regulation of angiogenesis after ICH.
Abstract WP31: Asymmetrical Internal Veins Sign In Acute Ischemic Stroke: A New Marker For Poor Collateral Circulation.
Authors: Dinia Lavinia , Carrera David , Raquel Delgado-Mederos , Joan Martí-Fàbregas , Munuera Del Cerro Josep Lluis
Published: July 2021

INTRODUCTION:
Changes in venous drainage imaging have been directly related to parenchymal damage in acute ischemic stroke during endovascular treatment. Venous asymmetry assessed by CT prior to treatment may be directly related to delayed flow in the hypoperfused territory.

We investigated the prevalence of asymmetry in internal cerebral vein (AIV) drainage and its correlation with collateral flow in patients with acute ischemic stroke by a multimodal CT protocol.

Subjects and methods:
We retrospectively evaluated clinical and radiological data of 29 consecutive patients with acute anterior circulation ischemic stroke within 6 hours from symptoms onset. Collateral status was graded as good or poor depending on the extent of contrast visualized distal to the occlusion on CT angiography (CTA). Presence and AIV (analyzed by density units, time to peak and volume) and arterial collateral score were blinded assessed on CT perfusion (PCT), CTA source images (CTASI) and MIP reconstructions.

Results:
We included 29 patients, with a median age of 77 ± 15 y, and 31% of them were men. Median baseline NIHSS was 11 ± 7. Mean infarct ASPECTS was 9.3 ± 1 and size 2 cm3 ± 4. Asymmetrical veins were present in 33% of patients. This sign was more prevalent in patients with proximal occlusions than in distal occlusions (67% versus 33%) and in patients with poor collaterals compared to those with good collaterals (62% versus 29%).

AIV was significantly associated with increasing age (p= 0.03), increasing baseline NIHSS (p= 0.02) and poor collaterals (p=0.01).

Presence of AIV reached high specificity (93%) and good sensitivity (66%) for poor arterial collaterals prediction (p=0.001).

Conclusion:
Impairment of venous circulation, assessed by means of AIV, is present in one third of the patients and was associated with stroke severity and low effectiveness of collateral flow.

Presence of internal veins asymmetry is highly specific in detecting poor collateral circulation in acute stroke and may be a predictor of clinical and radiological severity, possibly useful for patients selection in planning reperfusion therapy strategies.
Abstract WP312: Relaxation Techniques Profile Of Self-reported Stroke Survivors: Analysis Of The National Health Interview Survey
Authors: Pandey Abhishek , Gallagher Martina R , Soni Prabhat ,   A.P. Med P.C. Rsch Div Investigators
Published: July 2021

INTRODUCTION:
There is limited description of the various relaxation techniques used by stroke survivors at a population level.

Objective:
We examined and described differences in relaxation techniques among stroke survivors from a nationally representative survey.

Methods:
Analysis was based on the 2007 National Health Interview Survey (NHIS) (n=23,393 adults (>18 years); mean age=45.8; female=51.7%). The NHIS is a cross-sectional household interview survey utilizing a multistage area probability design. Data was collected by trained personnel from the US Census Bureau in face-to-face interviews. Respondents provided anthropometric and sociodemographic data and information on physician-diagnosed chronic conditions, including self-reported stroke and use of relaxation techniques (i.e. acupuncture, deep breathing exercises, guided imagery, meditation (also asked if ever), progressive relaxation, stress management class, support group meeting, practice yoga) in the past 12 months. All analyses were performed using SAS 9.3 (SAS, Inc, Cary, NC), applying relevant sample weights.

Results:
Self-reported stroke prevalence was 2.4% (Unweighted:647; weighted: 5,425,685). Self-identified stroke survivors were more likely to report being female, obese, widowed, and Black/African Americans compared to non-stroke survivors (p<0.05). The most common relaxation technique was deep breathing exercises (13.1%) and least reported was utilization of stress management class (1.1%). Stroke survivors were more likely to report using acupuncture and employing deep breathing exercises (2.2% versus 1.4% and 13.1% versus 12.4%; p<0.05) compared to those not reporting stroke. They were also less likely to practice yoga in the past 12 months compared to non-stroke survivors (2.3 % versus 5.8% ; p<0.05). Other relaxation measures comparisons were not significant.

Conclusions:
Our analysis of epidemiologic stroke data suggests that individuals who survived stroke utilize relaxation techniques such as acupuncture and deep breathing. Future research is needed to evaluate if these relaxation techniques assist stroke survivors with better health and quality of life outcomes in long-term rehabilitation.
Abstract WP317: High Metabolic Cost of Mobility and Balance Activities in Individuals Post-Stroke
Authors: Kafri Michal , Myslinski Mary Jane , Gade Venkata , Deutsch Judith E
Published: July 2021

Purpose:
Metabolic cost of walking at a comfortable speed for individuals post-stroke is higher than for healthy individuals. However, metabolic cost of other activities, relevant for community activity, such as transfer from sitting to standing and walking over obstacles, has not been reported. Hence, the aim of this study was to measure metabolic cost of mobility and balance activities for individuals post-stroke, and to assess the hypothesis that it will be higher than for healthy individuals.

Methods:
Eleven post-stroke (7 men, age 49.5±12.2), and 8 healthy (3 men, age 46.8±6.7) individuals of comparable height and weight participated in the study. Gait speed was measured and motor impairment was evaluated using the Fugl-Meyer test. Four activities were tested for their metabolic cost; walking at a comfortable speed, walking over an obstacle course, sit to walk and standing on balance foam while reaching forward. Each activity was performed repeatedly for 8 minutes, while metabolic measures were recorded. In addition, distance covered, or number of repetitions completed, during the activity were recorded. Metabolic cost of each activity was calculated by dividing the mean oxygen consumption of the last four minutes of the activity by the number of repetitions or walking speed.

Results:
The Fugl-Meyer scores for post-stroke individuals for lower and upper extremities were 23.6±6.5 and 43.6±19.3 respectively. Comfortable gait speed was 0.8±0.3 m/sec. for post-stroke and 1.4±0.1 m/sec. for healthy individuals. Groups were not significantly different in weight and height. Metabolic cost and between-group comparisons are shown in the table.

Conclusion:
The metabolic cost of the activities was significantly higher for individuals post stroke than for healthy, suggesting that rehabilitation programs should aim to improve economy of movement.
Abstract WP32: Heterogeneity of Oxygen Extraction Fraction Weighted MRI in Acute Ischemic Stroke Patients
Authors: Wu Ona , Copen William A , Kwong Kenneth K , Kursun Oguzhan , Mocking Steven , Benner Thomas , Reese Timothy G , Schaefer Pamela W , Singhal Aneesh B
Published: July 2021

Background:
Increases in oxygen extraction fraction (OEF) are postulated to be a marker of tissue at risk of infarction in acute ischemic stroke patients. R2’, a parameter that can be measured rapidly using an asymmetric spin echo MRI sequence (ASE), can be considered an OEF-weighted MRI metric, being a combination of both OEF and venous cerebral blood volume. We investigated the feasibility and utility of OEF-weighted MRI in acute stroke.

Methods:
Adult ischemic stroke patients were prospectively enrolled in a 3T MRI study of patients imaged within 48 hours of stroke onset. Only the subset of patients whose MRI included ASE and whose DWI was positive for acute infarction was analyzed. Acquisition time for ASE was 1.5 min. R2’ maps was calculated from ASE data on a voxel-wise basis after motion correction and smoothing. DWI and follow-up images (FU), when available, were co-registered to the ASE. Mean R2’ values and coefficient of variance (mean/SD) within the lesion, ipsilateral DWI-normal (IPS) and contralesional hemisphere (CNL) were calculated and compared.

Results:
Fifteen subjects met the inclusion criteria with mean±SD age 64±14 years, median admission NIHSS 12 [IQR 7-15] and time from onset to MRI 39±30 h. Eleven patients were imaged after tPA therapy. Both elevated and decreased R2’ were observed within DWI and FU lesions. Mean R2’ values in the DWI lesion (6.0±1.5 Hz) were significantly lower than CNL (7.2±0.6 Hz, P=0.02) and IPS (7.2±0.7 Hz, P=0.01). Coefficient of variance in R2’ values in the DWI lesion were also significantly lower than IPS (P=0.03) or CNL (P=0.05). For the 12 subjects with follow-up imaging, mean R2’ in tissue that eventually infarcted (5.7±1.8 Hz) was significantly lower (P=0.02) than in ipsilateral tissue surrounding the eventually infarcted lesion (7.3±0.6 Hz) but not significantly lower than DWI lesion values (6.1±1.6 Hz).

Discussion:
In this study using ASE, decreased OEF-weighted MRI values can potentially reflect tissue that is destined for infarction since OEF is proportional to cerebral oxygen metabolic rate. Increased OEF-weighted MRI values may be a sign of tissue that is at risk of infarction. Studies including measures of CBF and CBV will allow for better discrimination of tissue status.
Abstract WP320: Patient-centered Predictors of Rehabilitation Care after Acute Stroke
Authors: Stein Joel , Bettger Janet P , Sicklick Alyse , Hedeman Robin , Magdon-Ismail Zainab , Schwamm Lee H
Published: July 2021

INTRODUCTION:
Rehabilitation plays a key role in helping stroke survivors return to the community. Assessment of rehabilitation needs in the acute hospital is widely acknowledged as important, but has not been well defined. We therefore conducted a pilot study to examine the feasibility of completing a standardized assessment of stroke patient rehabilitation needs in acute hospitals and determine the relationship with discharge destination.

Methods:
Twenty-two hospitals within the Northeast Cerebrovascular Consortium (NECC) (consisting of CT, MA, ME, NH, NJ, NY, RI, and VT) participated in a pilot program to collect specific clinical measures believed to predict rehabilitation needs: sociodemographics, pre-morbid disability (modified Rankin Scale, mRS), level of ADL assistance needed (Barthel Index), cognition (Short Portable Mental Status Questionnaire) and caregiver availability. Data were collected as an extension of the American Heart Association’s Get With the Guidelines-Stroke program on 836 patients in 2010-11, of whom 630 (80%) had sufficient data recorded for further analysis. The Barthel index was divided into quintiles for analysis.

Results:
In multivariable analysis, only the Barthel Index was independently associated with return home vs. discharge to institution-based rehabilitation post-stroke (p<0.001; c=0.902), with 92% of patients with Barthel Index of 85 or higher returning home, and 91% of patients with Barthel Index of 20 or below receiving institution-based rehabilitation. In multivariable analysis comparing patients referred to Inpatient Rehabilitation Facilities (IRF) versus Skilled Nursing Facilities (SNF), no association was seen with the Barthel Index, but patients with pre-morbid disability (mRS=2-5) were more likely to receive SNF care (OR=2.86, 95%CI=1.66-4.93) than those without pre-morbid disability (mRS=0-1).

Discussion:
We conclude that formal assessment of rehabilitation needs of stroke survivors in the acute care setting was practicable. The Barthel Index was highly predictive of receiving home vs. SNF/IRF rehabilitation care, and among those patients not returning directly home, pre-morbid mRS was predictive of receiving IRF versus SNF care.
Abstract WP333: A Simplified Score to Predict Stroke Risk in Nonvalvular Atrial Fibrillation
Authors: Garrard Clare T , Amin Mahesh , Hakki Abdul H
Published: July 2021

The widely used
CHADS2
score has been validated to predict the annual stroke risk (SR) in patients with non-valvular atrial fibrillation (AF). The
CHA2DS2-VASc
score incorporates 5 more risk factors including female gender, age 65 to 74 years, and peripheral arterial disease (PAD), prior myocardial infarct or aortic plaque. The two schemes have different SR and require separate tables to calculate SR
(Table 1)
.

Table 1
An acronym
(AFIB)2S4
+
PaF2 (Table 2)
is presented to predict SR that increases with higher scores, simplifies memorization of the score, incorporates all known risk factors and more accurately predicts SR without the use of tables.

Table 2
The SR per 100 patient-years is calculated by adding
(AFIB)2S4
+
PaF2
scores. For example if all are positive including age 75 years then the SR is 15%, while if all are negative, including age <65 and male gender, then the SR is 0.

To determine the predictive accuracy of the three scores, we reviewed the records of 100 consecutive patients admitted with acute cerebrovascular events and AF. The results showed 83% would have been classified as moderate to high risk (score>1) by
CHADS2
, 95% by
CHA2DS2-VASc
, and 99% by
(AFIB)2S4
+
PaF2.
(P <0.012).

Conclusion:
Compared to the
CHADS2
, and
CHA2DS2-VASc
,
(AFIB)2S4
+
PaF2
more accurately predicts risk of acute cerebrovascular events in patients with AF.

It is easy to remember and does not require the use of tables to assess SR in AF. Further studies are needed for validation.

PEN ©
Abstract WP339: Reducing Door-to-Needle Time for Acute Ischemic Stroke Thrombolysis in a Community Hospital
Authors: Linzey Jennifer , Shilling-Brewer Janet , Thibodeaux Mariaelena , Cory William , Berger Paulo , Neil William
Published: July 2021

Reducing door-to-needle time [DTNT] for delivery of IV t-PA to acute ischemic stroke [AIS] patients improves functional outcome [1, 2]. Our community hospital sought to evaluate methods for improving DTNT in a non-academic center.

Weekly debriefings of all AIS cases were conducted to develop process improvement strategies using a rapid cycle test of change model; which allows for quickly implementing changes in organizational structure [3].

Paired t-test was used to compare mean DTNT before and after implementation of changes.

First, stroke patients arriving by ambulance were transferred directly to CT scan, eliminating the time delay of gurney transfers. The stroke team then started formal stroke debriefs, wherein areas for improvement were sought on an individual basis. In response to a delay due to IV tubing issues, pharmacy included tubing with the t-PA. Next, the algorithm was changed to allow ED staff to order t-PA while neurologist was en route. Later, a neurologist was assigned to be on-site at the hospital for immediate response. Pharmacy began hand delivering t-pa after a delivery delay due to miscommunication. After triage delays for atypical strokes, ED began pre-shift nursing messages and displayed posters that emphasized atypical stroke symptoms. Pharmacy designated one phone number to quickly communicate t-PA was to be given. The process improvements resulted in a significant reduction of average monthly DTNT by 7.56 minutes (p = 0.02) (Figure 1).

Weekly debriefings of AIS cases lead to policy changes which significantly reduced DTNT in our community hospital.

Saver, J.L., et al.: The “Golden Hour” and Acute Brain Ischemia; Stroke. 2010;41:1431-1439

Lees KR, et al: Time to treatment with intravenous alteplase and outcome in stroke; Lancet. 2010 May 15;375(9727):1695-703.

Langley G.L.: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance 2009, 2
nd
ed. Jossey Bass, San Francisco
Abstract WP359: Achieving Target: Stroke Honor Roll Status through the Utilization of 9 Best Practice Strategies
Authors: Garland Jennifer
Published: July 2021

Background:
Target: Stroke is a national quality initiative of the American Heart Association/American Stroke Association with the goal of improving <60 minute door-to-needle times (DTN) for at least 50% of patients receiving IV rt-PA. (AHA/ASA, 2012)

Purpose:
To improve DTN times <60 minutes at an urban Primary Stroke Center in South California through the utilization of the Target: Stroke national quality initiative.

Methods:
Retrospective data analysis for 11 IV rt-PA receiving patients in the Get With The Guidelines-Stroke (GWTG-Stroke) database from 11/01/2011 to 01/31/2012. Employment of 9 Target: Stroke Best Practice Strategies: Advance Hospital Notification by EMS (Emergency Medical Services), Rapid Triage Protocol and Stroke Team Notification, Single Call Activation System, Stroke Tools, Rapid Acquisition and Interpretation of Brain Imaging, Rapid Laboratory Testing, Rapid Access to Intravenous IV rt-PA, Team-Based Approach, and Prompt Data Feedback.

Results:
The hospital received advanced hospital notification by EMS for 10 out of 11 (90.9%) IV rt-PA receiving patients. 100% of the patients were rapidly triaged, the stroke team was notified via single call activation & overhead page (stroke alert), and the appropriate thrombolytic stroke order sets were implemented (Stroke Tools). Rapid acquisition and interpretation of brain imaging were measured. CT Scan order to CT complete turn-around-time (TAT) averaged 12 minutes. CT Complete to CT Read TAT averaged 11.33 minutes.Average PT/INR and PTT TATs were 26.1 minutes. Rapid access to intravenous IV rt-PA was mixed by the Emergency Department pharmacist at the bedside for 100% of patients. The Team-Based Approach and prompt Data Feedback were practiced by holding monthly Stroke Steering Committee meetings that included interdisciplinary team members and disseminating data. Eight out of eleven (72.7%) acute ischemic stroke patients treated with IV rt-PA received the medication <60 minutes. Median door-to-needle (DTN) time for patients treated with IV rt-PA: 42 minutes.

Conclusion:
By employing 9 Target: Stroke Best Practice Strategies at an urban Primary Stroke Center in South California, the hospital was able to achieve Target: Stroke Honor Roll status from 11/01/2011 to 01/31/2012.
Abstract WP370: The Swedish Quality Register for Transient Ischemic Attacks: design and initial results
Authors: Norrving Bo , Appelros Peter , Terent Andreas , Wester Per ,   for the Riks-Stroke Steering Committee
Published: July 2021

INTRODUCTION:
Several national quality registers for stroke have been established, but they have generally not included TIA, an essential part of acute cerebrovascular disease with a high preventive potential. We report the 1st results from the world’s 1st national quality register on TIA.

Methods:
In 2011 a TIA module was added to the Swedish Stroke Register (Riks-Stroke). Indicators included basic demographics, risk factors, ABCD2 score, brain and vascular imaging, cardiac arrhythmia diagnostics, medical treatments, and anti-smoking advice.

Results:
During the initial half-year (January to June 2011), 3293 TIA patients were registered at 55 of Sweden’s 75 hospitals. Mean age for men was 71.1 years and for women 74.6 years; 2 and 3.5 years lower than for stroke-patients registered in Riks-Stroke. Mean ABCD2 score was 4.1. Atrial fibrillation (AF) was recorded in 19 % of patients. 96.4 % were examined with CT, 8.1 % with MRI, 69.5 % with neck vessel imaging, and 31.4 % with Holter monitoring (with large variation across hospitals: 0-80 %). At discharge, 83.9 % were treated with antiplatelets whereas 10.8 % were treated with warfarin (57 % of those with AF). About two thirds were treated with blood pressure lowering drugs and statins, with substantial variation across hospitals. Of smokers (13 % overall), 85 % were given anti-smoking advice.

Conclusions:
A national quality register for TIA is feasible. Compared to epidemiological data we estimate that the register currently covers about two thirds of all TIA in Sweden. Many aspects of diagnostics and therapy appeared satisfactory, but there were wide variations in cardiac arrhythmia diagnostics, and one third or more were not appropriately treated with warfarin, blood pressure lowering drugs, or statins.
Abstract WP373: A Novel High-risk TIA and Minor Stroke Rapid Assessment Day-unit to Improve Quality of Care and Patient Outcomes
Authors: Cayley Anne , Abraham Jemini , Kalman Libby , Jaigobin Cheryl , del Campo Martin , Silver Frank L , Casaubon Leanne K
Published: July 2021

Background:
About one in four ischemic strokes are preceded by a TIA; 43% of TIAs occur within one week before stroke. Patients with a TIA require urgent assessment, risk stratification, and preventative treatment, but often cannot access a Stroke Prevention Clinic in a timely fashion. Therefore, these patients are often admitted to hospital for evaluation but it is unclear if inpatient evaluation is optimal or specifically necessary for this patient population.

Methods:
We developed a novel high-risk TIA and Minor Stroke (TAMS) day-unit to provide rapid access to patient assessment, investigations, initiation of prevention strategies, and stroke prevention education. The TAMS Unit patient assessments were based on a collaborative model led by stroke Nurse Practitioners and an attending stroke Neurologist. All patients had cerebrovascular imaging (CT angiography, MR angiography, or carotid Doppler if there were exclusions to CT or MR angiography), and as appropriate, echocardiography and Holter monitoring initiated at the TAMS Unit visit. We evaluated the feasibility of this novel care model. Outcomes including time to assessment, investigations, and treatment for high-risk TIA/stroke etiologies and stroke risk factors, as well as return emergency department visits or readmissions within 30 days were assessed.

Results:
Between Sept. 6, 2011 and Aug. 8, 2012, 142 patients were seen in the TAMS Unit. Median time from emergency department visit to TAMS Unit assessment was 1 day. The final diagnosis was TIA in 41% of patients and minor stroke (NIHSS < 4) in 27.5% of patients. Atrial fibrillation was diagnosed in 8 (5.6%) patients; anticoagulation was initiated promptly upon diagnosis. High-grade carotid stenosis was diagnosed in 4 (2.8%) patients and these patients were referred for urgent endarterectomy. There were 12 (8.5%) patients that had a return visit to the emergency department within 30 days; 2 (1.4%) with stroke, 8 (5.6%) with recurrent TIA or fluctuating symptoms, and 2 (1.4%) with other diagnoses.

Conclusion:
Our novel TAMS Unit is a feasible care model that provides rapid access to assessment and treatment of high-risk TIA and minor stroke patients, and is another level of care between hospital admission and the outpatient Stroke Prevention Clinic.