bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract WP26: Use of Balloon-guide Catheter Bridges the Difference in Technical Outcomes Between Adapt and Stent Retriever Thrombectomy for Ischemic Stroke - Insights From STAR Collaboration
Authors: Alawieh Ali M , Chalhoub Reda , Anadani Mohammad , Eid Maya , Almallouhi Eyad , Arthur Adam , Kim Joon-Tae , De Leacy Reade , Psychogios Marios , Maier Ilko , Rai Ansaar , Grossberg Jonathan , Keyrouz Salah , Fargen Kyle , Dumont Travis , Kan Peter , Starke Robert M , Spiotta Alejandro
Published: June 2021

Introduction:
Recently completed randomized controlled trials comparing aspiration thrombectomy (ADAPT) to stent retriever thrombectomy (SRT) demonstrated similar clinical outcomes, but faster thrombectomy procedure time in the ADAPT group. This study evaluates the difference in technical outcomes between ADAPT and SRT combined with balloon-guide catheters (BGC).

Methods:
Patients undergoing thrombectomy for acute ischemic stroke at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Data was collected retrospectively from patient charts, procedure notes, and patient follow-up in neurology clinics. Clinical endpoint was the modified Rankin score (mRS) at 90-days, and technical outcomes were procedure time, total attempts, and mTICI scores.

Results:
The study included 2,016 patients (mean age 69±15) who underwent stroke thrombectomy using ADAPT (46%), SRT (46%), or SRT+BGC (8%). Similar baseline characteristics were observed between the three groups, and no significant difference in mRS scores at 90-days between the three groups in univariate and multivariate analyses. Thrombectomy performed using SRT+BGC required significantly shorter procedure time compared to SRT (35 vs 61 min, p<0.001) that was comparable to ADAPT (36 min, p>0.1). However, use of SRT+BGC required significantly lower number of aspiration attempts compared to ADAPT (median 1 vs. 2, p<0.05). On multivariate linear regression, use of SRT+BGC independent predicted a significant reduction in procedure time compared to SRT (coefficient=-30.6, p<0.001), and significantly lower number of attempts compared to ADAPT (coefficient=-0.4, p=0.01). SRT+BGC was an independent predictor of higher mortality compared to ADAPT (OR=2.4, p<0.01), despite comparable rates of favorable outcomes (mRS 0-2) between the two groups. Use of SRT+BGC was not an independent predictor of symptomatic hemorrhage or complications compared to SRT or ADAPT.

Conclusions:
This study shows that although ADAPT allows for faster procedure time compared to SRT, the use of BGC in SRT allows for a comparable procedure time to ADAPT with similar overall rates of favorable outcome, complications and hemorrhage. Mortality was higher with the use of BGC compared to ADAPT.
Abstract WP263: Increased Cardiac Inflammation and Atrial Fibrillation Inducibility in Aged Females: The Niche for Cardio-Embolic Strokes?
Authors: Manwani Bharti , Inam Mehmet Enes , Morales Diego , Gelinas Bret , Lee Juneyoung , McCullough Louise
Published: June 2021

Background:
Elderly women have higher morbidity, mortality and disability after stroke compared to age-matched men. Cardio embolism from atrial fibrillation (AF) remains the primary cause of severe strokes in elderly women. Why females have higher rates of atrial arrhythmias and embolism as they age is unknown. Studying differences in atrial substrate inflammation and arrhythmogenesis may help us understand these sex differences.

Methods:
Aged male and female C57BL6 wild type mice (18-20 months old) were injected with carbachol 50μg/kg for AF induction and ambulatory telemetry monitors were implanted. AF events were analyzed using Ponemah software and LabChart software for one day. Another cohort of naïve aged wild type mice were sacrificed and intracardiac perfusion was performed. Hearts were collected and prepared into a single cell suspension using series of mechanical and enzymatic digestion steps. The cells were stained with antibodies for F4/80, Ly6C, CD11b, CD11c, and Gr1 antibodies. Sample data was acquired on a Cytoflex and analyzed using FlowJo software.

Results:
Aged females had significantly higher AF events, (110.7± 22.6, n=6), as compared to aged males (13.7±10.8 events, n=4), p=0.05. Flow cytometry showed that aged females have significantly more macrophages (CD11b
+
/F480
+
) (102.6±18.5) as compared to aged males, 26.6±3.4, p=.01, n=3/group. There were also significantly more monocytes (CD11b
+
/Ly6c
+
) in aged wild type females (176.6±50.8) vs. aged males (44.3±13.2), p=0.05, n=3/group. No significant difference was seen in dendritic cell numbers (CD11c
+
), p=0.3, n=3/ group.

Conclusion:
Our study shows that aged females have higher rates of AF after chemical induction as compared to males. They also have higher monocyte and macrophage populations in cardiac tissue as compared to aged males. This suggests that there is increased baseline cardiac inflammation in aged females, which may be the niche for arrhythmia generation in females. This in itself may lead to increased stroke risk. Anti-inflammatory therapies that control atrial substrate inflammation may be an important potential target for stroke prevention in women. Quantification of brain embolic events using MRI and Fluoro-jade staining will also be presented.
Abstract WP27: Patient Age and Outcomes of Those Receiving Endovascular Thrombectomy Treatment in San Diego County
Authors: Kenner-brininger Amelia , Olson-Mack Lindsay , Calzone Lorraine , Koenig Kristi L , Hemmen Thomas M
Published: June 2021

Background:
Endovascular thrombectomy (EVT) after Ischemic Stroke (AIS) has shown to improve outcomes in multiple large clinical trials. While most guidelines lifted the age restriction, few patients enrolled in clinical trials were over 79 years of age. We studied EVT over time in San Diego County as it relates to patient age. We sought to understand age distribution of patients receiving EVT, frequency by which patients 79 and older received treatment, and whether that frequency changed over time.

Methods:
We included AIS patients with a reported age and NIHSS from 10 EVT capable centers from July 2016 through December 2018 from the San Diego County EMS Stroke Registry. We analyzed frequency of EVT by patient age, last known normal (LKN) to groin puncture time, NIHSS and hospital discharge disposition.

Results:
Between July 2016 and December 2018, of 7,049 AIS patients, 659 (9.3%) received EVT. The mean (±SD) age of EVT patients was 71.9 (±15.6) years, ranging from 24 to 104 years old. Of these patients, 250 (37.9%) were >79 years. On average (±SD), 22.1 (±4.2) patients received EVT per month. Rate of EVT use among all AIS patients did not change over time (p=.24). On average (±SD) 8.4 (±3.3) patients >79 years underwent EVT per month. Rate of EVT among patients >79 years did not change over time (p=.31). EVT rate among patients ≤ 79 years increased over time (p=.02). EVT patients >79 years had a mean (±SD) initial NIHSS of 19.2 (±8.2) compared to EVT patients ≤ 79 years NIHSS 16.0 (±8.6) (p=.000002). Overall mean (±SD) LKN to groin puncture was 6.2 hours (±7.0), >79 years 5.6 (±5.7), ≤ 79 years 6.5 hours (±7.6) (p=.11). EVT patients >79 years were discharged to a Skilled Nursing Facility (SNF) (32.9%), died in-hospital (19.0%), and transferred to acute care (15.9%); patients ≤ 79 years were discharged to home (35.2%), SNF (17.6%), and Inpatient Rehabilitation Facility (15.7%).

Conclusion:
Endovascular thrombectomy for patients older than 79 years accounts for nearly one in four patients receiving EVT. The frequency of EVT use in the elderly did not change over time while use in patients under age 80 increased slightly. However, overall use of EVT remained consistent. Older patients receiving EVT had a higher NIHSS and were more commonly discharged to a SNF compared to younger patients.
Abstract WP279: Evaluation of a Novel Point-of-care Neuromonitoring Device to Detect Large Vessel Occlusion in Suspected Acute Stroke Patients
Authors: Wilcox Madeleine R , Berti Liam , Maza Andrew , Kesinger Matthew
Published: June 2021

Study Objectives:
Several prehospital stroke scales have been developed to provide quick and accurate triage to facilitate timely treatment. This study evaluated a portable, experimental EEG device using AI as a tool for detection of acute stroke and large vessel occlusion (LVO) among patients with neurological deficits. Both device performance and feasibility in the emergent setting were assessed.

Methods:
This observational study enrolled a convenience sample of emergency department (ED) patients evaluated for suspected stroke within 24 hours of symptom onset. LVO and stroke status were determined by local neuroradiologists blinded to device output. LVO was defined as an acute occlusion of any of the following arteries: ICA/MCA-(M1 or M2)/vertebral/ basilar. Controls were neurologically normal subjects (NIHSS=0).

Results:
From May 2018 to July 2019, eight urban US stroke centers enrolled 89 subjects being evaluated for stroke. In suspected stroke subjects, 68 had stroke (76%) and 23 had LVO (26%). Mean (± SD) age was 68 (± 14), 36% were female, and the median (IQR) NIH stroke score was 6 (3 - 12) among suspected stroke subjects. The median last known well time was 327 minutes (196 - 577). Device performance for detecting LVO is shown in Table 1. There were no severe adverse events related to use of the device.

Conclusion:
The neuromonitoring device performed well in identifying LVO in patients presenting with suspected stroke. The performance of the neuromonitoring device in the acute setting indicates that it may be able to support prehospital decision making when triaging suspected stroke subjects. Additional studies with larger sample sizes are needed to validate this study’s findings.
Abstract WP283: The Multiple-Encounter Multiply-Thrombolysed Telestroke Patient - A Unique Patient Population
Authors: Morton Johanna L , Northington Diamond K , Jolly B. Tilman
Published: June 2021

Background:
Thrombolysis with alteplase is the standard of care for the treatment of eligible patients presenting with acute ischemic stroke (AIS). Many hospitals do not have access to in-person cerebrovascular expertise, and utilize telestroke services for the remote diagnosis and treatment of AIS. Through this practice, an unusual subset of patients with multiple presentations having received thrombolysis several times has emerged. This study describes the largest known sample of this multiple-encounter population within a single teleneurology practice spanning 39 states over 4 years.

Methods:
A retrospective observational study of the experience of a single teleneurology practice serving over 400 hospitals from July 1, 2015 to June 30, 2019 was performed. The alteplase patient database was queried to identify patients with both multiple telestroke and multiple alteplase encounters. Demographic and clinical data were abstracted. Outcome analysis was restricted to those patients with available complete discharge data.

Results:
Within the queried period, 71 patients were identified to have had multiple encounters with the teleneurology practice, 46 males and 25 females. Of these, 36 patients were seen twice, 18 were seen three times, 10 were seen four times, and 7 had five or more encounters, with the maximum number of encounters of 26. Seven patients received care in multiple states. The overall alteplase rate was 58.2%. Alteplase was administered on more than one encounter in all 71 patients, with a maximum alteplase administration of 4 times in a single patient. The median NIHSS score in this population was 5. Of the 71 patients, all had stroke risk factors, 36.6% had noncerebrovascular neurological comorbidities, and 36.6% had psychiatric disease history. The symptomatic hemorrhage rate in this population was 0%.

Conclusion:
The observed phenomena of recurrent teleneurology encounters for patients presenting with suspected AIS symptoms and receiving alteplase at increased rates is not well-described and is poorly understood. Given the inherent risk and resource utilization associated with thrombolysis, further analysis of the characteristics of this patient population is warranted.
Abstract WP292: Temporal Trends in the Use of Ems Service as a Mode of Arrival by Acute Ischemic Stroke Patients
Authors: Ali Syed F , Schwamm Lee H , Onteddu Sanjeeva , Nalleballe Krishna , Patrice Kelly-Ann , Hemmen Thomas
Published: June 2021

Intro:
Utilization of emergency medical services (EMS) can increase the likelihood of appropriate therapy with IV tPA or endovascular intervention. We investigate the use of EMS services in three large states across the US during the past decade.

Methods:
Using GWTG stroke registry data from three large comprehensive stroke centers in the Northeast, South and West, we analyzed 9,251 stroke admissions from 01/2010 - 12/2018. Overall rates of EMS use and temporal trends were computed. Factors associated with EMS use were evaluated with univariate analysis.

Results:
Of the 9,251 patients, 29.2 % (2,697/9,251) presented via EMS service. Overtime use of EMS service increased from 29% in 2010-11 to 34% in 2018. Use of EMS increased among severe stroke patients but decreased among mild stroke patients. Patients presenting via EMS were older, more often females while less often African Americans. They had more stroke risk factors, including hypertension, diabetes, atrial fibrillation and previous stroke/TIA. Smokers less often use EMS services. Median NIHSS was higher among patients presenting via EMS, and those with altered level of consciousness used EMS more often. In-hospital intervention rates (IV tPA/endovascular) were higher among patients presenting via EMS.

Conclusion:
Our results showed that after extensive EMS education in most parts of the study states, stroke presentation has increased via EMS overtime. Disparity in the use of EMS still exists with African Americans using the service less often. Patients should be encouraged to use EMS services and decrease delay in presentation which can results in higher rates of intervention.
Abstract WP302: Simulating the Impact of Reducing Door-in-Door-out Times for Acute Stroke Transfers
Authors: Khorzad Rebeca , Gutstein Jacob , Mei Roger , Frank Isaac , Smith Sawyer , Watts Adam , Perry Ohad , Ankenman Bruce , Richards Christopher , Parnianpour Zahra , Holl Jane , Prabhakaran Shyam
Published: June 2021

Introduction:
Some acute stroke (AS)patients require transfer to comprehensive stroke centers (CSCs) for time-sensitive, advanced treatments that lead to better outcomes. However, door-in-door-out (DIDO). PSC DIDO processes at primary stroke centers (PSCs) can be prolonged and result in delay or failure to deliver the advanced treatments at the CSC. We simulated the impact of reducing PSC DIDO times on the rate of inappropriate transfers to CSCs, a potential consequence of such efforts.

Methods:
Clinicians from3Chicago-area CSCs and 3 affiliated PSCs and the two main ambulance providers created a PSC DIDO process map Patient-level data from the 3 PSCs (N-108) and estimates from the literature were used to determine the distribution, range, or proportion of each step in the process. Datainputs were varied using Python™ in simulations with 100 replications. Outputswere DIDO time, % patients transferred to CSC, and % inappropriate CSC transfers. Sensitivity analyses assessed most impactful factors on DIDO time.

Results:
Three key decision points for transfer of an AS patient to a CSC were identified:
(1)
After stroke code activation;
(2)
After telestroke consultation; and
(3)
Post-tPA administration(most common current process). The figureshows that increasing PSC transfer ratesimmediately after stroke code activation by 5% decreased DIDO time by 10 minutes (11%), while increasing the inappropriate CSC transfer rate by 4%. Sensitivity analyses show that total DIDO time is most sensitive to the proportion of PSC hemorrhagic strokes, accuracy of AS detection at triage, and proportion of AS patients arriving by EMS.

Conclusions:
A strategy of earlier detection of acute stroke at triage, followed rapidly by stroke code activation and streamlined transfer of AS patients is likely to benefit from CSC care is predicted to a large impact on DIDO times, with a very small trade-off in increasing inappropriate transfers.
Abstract WP330: Process Measures and Outcomes in Defuse 3 Trial by Day and Week Time Patterns
Authors: Mlynash Michael , Lansberg Maarten G , Kemp Stephanie , Christensen Soren , Marks Michael P , Heit Jeremy J , Albers Gregory W
Published: June 2021

Introduction:
Several studies identified temporal variations in stroke care and suggested that quality of care declines during off-hours and on weekends.

Methods:
We specified 2 time definitions: a) 8-hour blocks: night (midnight – 7:59), day (8:00 – 15:59), evening (16:00-23:59); b) weekday vs. weekend. We compared process measures and outcomes of the EVT-treated DEFUSE 3 patients based on these definitions. To assign patients to time-blocks, we used date and time of admission to hospital that performed EVT.

Results:
92 patients were randomized to EVT treatment: 30% arrived to the treating hospital at night, 49% at day, 21% at evening. Mean age by arrival time 71±14, 70±12, 63±15 (p=0.09); NIHSS 17±5, 15±6, 15±8 (p=0.40); female 39%, 51%, 63% (p=0.27). Weekend admission occurred in 21%. Weekday vs weekend mean age 68±14 vs 72±11 (p=0.19); female 53% vs 37% (p=0.20), higher weekend NIHSS 15±6 vs 18±6 (p=0.04). Onset to arrival at the EVT center varied by time of day: (hrs:mins) 7:04±2:43 night, 8:05±3:01 day, 4:51±2:30 evening, p<0.001. However, day admissions tended to be wake-up/not witnessed strokes more often: 76% vs. 47% evening and 64% night, p=0.09. Transfer times for 57 transfer patients were similar: mean 3:06, 3:09, 3:38. Time from arrival at the treating hospital to groin puncture varied by presenting times: 2:28±1:11 night, 1:45±0:46 day, 2:36±2:32 evening (p=0.02). Time-metrics for weekday vs weekend were similar. Rates of successful reperfusion, 90-day mRS and mRS=0-2 did not differ by time of day or week. There was higher 90-day mortality (32% vs 10%, p=0.02) and in-hospital mortality (21% vs. 4%, p=0.03) on weekend. Symptomatic ICH also occurred more commonly in weekend admits (21% vs 3%, p=0.01). However, after adjustment for age and NIHSS, presenting on weekend was not independently associated with mortality, p=0.13.

Conclusions:
DEFUSE 3 patients admitted during the day had the longest time from last known well to arrival at the study site due to the high percentage of wake-up strokes admitted during this time period, however, these patients had the shortest arrival to groin puncture times. Although mortality rates were higher for patients who presented on weekends, this may be explained by the fact that these patients were older and had higher NIHSS.
Abstract WP341: Is it Safe to Treat Patients With Acute Minor Stroke and Tia as Outpatients?
Authors: Hastrup Sidsel , Johnsen Soren Paaske , Jensen Martin , von Weitzel-Mudersbach Paul , Simonsen Claus Ziegler , Hjort Niels , Møller Anette Torvin , Harbo Thomas , Poulsen Marika Suzuki , Iversen Helle Klingenberg , Damgaard Dorte , Andersen Grethe
Published: June 2021

Objective:
To evaluate the effects of an acute 7-day outpatient clinic for minor stroke or transient ischemic attack (TIA).

Methods:
We performed a prospective cohort-study using all patients from an outpatient clinic for patient with suspected minor stroke and TIA between September 2013 and August 2014. The clinic opened in May 2012 as part of centralization of the stroke services in Central Region Denmark. For comparison, we used a matched historic cohort from the same hospital between May 2011 and April 2012 (before the outpatient clinic) and a contemporary cohort from a comparable university hospital from the Capital Region without an outpatient clinic. A risk-assessment tool was used in the outpatient clinic to determine the risk of recurrent stroke and hence a need for a hospital admission.

Results:
The outpatient clinic cohort (OCC) consisted of 1076 patients and we confirmed a neurovascular diagnosis in 510 of the patients (47.4%). Of these, 215 had a stroke and 94 (43.7%) were discharged direct from the outpatient clinic. TIA was confirmed in 171 patients and of these 121 (70.8%) were handled without a hospitalization. In the stroke patients from the OCC there was a shorter length of acute hospital stay (median 1 day) compared to the matched historic cohort (median 3 days); adjusted length of stay ratio of 0.49 (0.33-0.71). Furthermore these stroke patients had a 30-day readmission rate on 3.2 % (0.6-5.7) compared to 11.6 % (6.99-16.2) in the historic cohort; adjusted hazard ratio of 0.23 (0.09-0.59) and increased quality of care captured in 10 process performance measures. We found similar results in comparison with the contemporary cohort. Furthermore, we saw a similar pattern when we compared TIA patients from the OCC to a matched contemporary cohort. According to the risk-assessment, 170 stroke or TIA patients had a ‘low risk’ and were treated without being admitted as inpatients. Only one of these patients experienced a stroke within 7 days (0.59%).

Conclusions:
Overall, the results showed the outpatient set up for minor stroke and TIA was safe and may be an advance compared to hospitalization in stroke units despite use of less bed days. Furthermore, the risk assessment used to select patients in need of an inpatient course seems useful.
Abstract WP347: The Effectiveness and Implementation of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Quality Improvement Program: An Exampleofa Learning Healthcare System in Action
Authors: Bravata Dawn M , Myers Laura J , Perkins Anthony J , Zhang Ying , Homoya Barbara J , Miech Edward J , Rattray Nicholas A , Giacherio Bernna , Kumar Meetesh , Penney Lauren S , Cheng Eric , Levine Deb , Sico Jason J , Myers Jennifer , Austin Charles , Baird Sean , Damush Teresa
Published: June 2021

Objectives:
Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) trial evaluated the implementation of a quality improvement (QI) program aligned with Learning Healthcare System principles to improve TIA care.

Methods:
A facility-based, stepped-wedge trial was conducted at six diverse sites. The intervention included five components: clinical programs, data feedback, professional education, electronic health record tools, and QI support. Implementation strategies included: team activation via audit and feedback, goal setting, reflecting and evaluating, and planning; external facilitation; and building a community of practice. The primary effectiveness outcome was the Without Fail rate (WFR); proportion of TIA patients who received all processes of care for which they were eligible among: brain imaging, carotid artery imaging, neurology consultation, hypertension control, anticoagulation for atrial fibrillation, antithrombotics, high/moderate potency statins. The primary implementation outcomes were the number of improvement activities completed and the Group Organization (GO) scores for providing and improving care (scale of 1-10).

Results:
The 6 PREVENT facilities cared for N=162 control period TIA patients and N=191 intervention period TIA patients. The mean facility WFR increased from 36.7% (baseline) to 53.9% (active implementation); p=0.002 (adjusted for temporal trend, hospital admission). The mean number of improvement activities completed during the 1-year implementation period was 26 (range 11-39). The mean facility GO scores increased: providing care, 1.2 to 6.5; improving care, 1.0 to 6.7.

Conclusions:
PREVENT advances three aspects of a learning healthcare system:
Learning from Data
(teams interacted with their facility’s performance data to explore hypotheses, plan QI activities, and evaluate change over time);
Learning from Each Other
(teams participated in monthly virtual collaborative conferences), and
Sharing Best Practices
(teams shared tools and protocols).
Abstract WP352: Factors Affecting Short and Long-Term Outcome of Patients Diagnosed as Stroke Mimic at Index Event
Authors: Akhtar Naveed , Kamran Saadat , Singh Rajvir , Bhutta Zain , Morgan Debby , Joseph Sujatha , Bourke Paula , Saqqur Maher , Imam Yahia , Amir Numan , Babu Blessy , Ojha Laxmi , Jose Namitha , Shuaib Ashfaq
Published: June 2021

Background:
Stroke mimics (SM) is a stroke-like clinical picture due to a disease other than cerebrovascular diseases. The causes of SM are diverse. Distinguishing SM from stroke is important to avoid unnecessary acute treatment and secondary prevention. PURPOSE: We hypothesized to evaluate short and long-term outcomes in terms of major adverse cardiovascular events (MACE) in patients who presented with SM.

Methods:
We evaluated a prospective cohort of Qatari patients with confirmed diagnosis of SM who presented to our hospital as suspected acute stroke between January 2014 and February 2019. We investigated the associated risk factors, short- and long-term risk of MACE in these patients. We calculated the modified Rankin score (mRS) at discharge and 90-days (short-term) and MACE (long-term) outcomes. To determine the independent predictor for MACE, the Cox proportional hazards regression analysis was used and summarized as hazard ratio and 95% confidential interval.

Results:
A total of 481 Qatari patients (mean age 57.5 ±18.0; 56.3% male) with diagnosis of SM were identified, of whom 126 (26.2%) patients were found to have MACE during follow up (36.7 months (95% CI 35.5-37.8). Patients who develop MACE were older (62.4 ±17.5 vs 55.7 ±17.9, p<0.001). Hypertension, diabetes and prior stroke and coronary artery disease was significantly more common in patients with MACE. High NIHSS on admission (2.5 ±4.1 vs 1.2 ±3.0, p<0.001), high glucose (7.5 ±2.2 vs 6.8 ±2.0, p= 0.005), lower HDL (1.0 ±0.3 vs 1.2 ±0.3, p<0.001) and extended length of stay at index event (3.9 ±5.6 vs 2.4 ±2.1, p<0.001) was higher in MACE. Patients with MACE had significantly worse outcome at discharge (46.0 vs 23.7%, p<0.001) and at 90-days (38.1 vs 0.4%, p<0.001). Once corrected, the long-term MACE-free survival function did not show any statistical difference between two groups

Conclusions:
Stroke mimics if associated with cardiovascular risk factors carry a poorer short and long-term prognosis after the first presentation. More aggressive reduction of cardiovascular risk may help in preventing such major cardiovascular events.
Abstract WP360: Long-Term Maintenance of Lifestyle Risk Factors in the General New Zealand Population Are Modulated by Psychosocial Distress, Health Beliefs and Socioeconomic Deprivation: A Mixed Methods Analysis
Authors: George Shwetha A , Krishnamurthi Rita V , Barker-Collo Suzanne , Parmar Priyakumari , Feigin Valery
Published: June 2021

Introduction:
Lifestyle-associated risk factors which constitute 74% of the global stroke DALYs can be mitigated through long-term
preventative health behaviour changes
(PHBCs). Ongoing motivation for PHBC engagement and maintenance may be influenced by psychosocial distress, socioeconomic deprivation and health beliefs. In New Zealand (NZ), investigation into such factors is scarce and forms the scope of this research.

Methods:
(1) Qualitative: Semi-structured interviews were conducted with 46 NZ participants recruited from the
Reducing the International Burden of Stroke Using Mobile Technology
E-health research program. Personal stroke susceptibility, barriers to/benefits of PHBCs, and coping with psychosocial distress were explored. Interviews were recorded, transcribed verbatim and thematically analyzed. (2) Quantitative: To study socioeconomic deprivation influences on food choices, 160 participants completed questionnaires on dietary habits and food choice motivations. Data were analyzed using descriptive and inferential statistics and linear regression modelling.

Results:
(1) Participants acknowledged the critical role of negative lifestyle risk factors in promoting a stroke event. Notwithstanding, such behaviours were favored to evoke instant, albeit short-lived relief during high stress, limiting motivation to initiate or maintain PHBCs. Perceived PHBC benefits were improved physical and mental health and confidence in avoiding future health risks. Inadequate support systems lowered participants’ self-efficacy in sustaining PHBCs. (2) Individual deprivation status was significantly associated with consumption of stroke-risk reducing foods (e.g., fruits) (
R

2

=0.20,
p
<0.000). Such participants and those residing in deprived neighborhoods were more likely to prefer foods that are readily available (
R

2

=0.10,
p
=0.02;
R

2

=0.11,
p=
0.02) and cheaper (
R

2

=0.29,
p
<0.000;
R

2

=0.55,
p
<0.000).

Conclusions:
Socioeconomic deprivation and psychosocial distress can promote risk-inducing lifestyle choices and limit motivation for PHBC engagement. Client-centred strategies may then be more successful in optimizing long-term PHBC maintenance than traditional, education-based prevention paradigms.
Abstract WP363: Trends and Disparities in Utilization of Palliative Care for Ischemic Stroke Patients Undergoing Thrombolytic Therapies: 10-Year Analysis of Nationwide Data
Authors: Chu Kristie , Jones Erica , Bambhroliya Arvind B , Meeks Jennifer R , Vahidy Farhaan
Published: June 2021

Introduction:
We characterize 10-year nationwide trends in utilization of palliative care (PC) for ischemic stroke (IS) patients and describe in-hospital outcomes and costs for IS patients receiving PC, particularly those with acute thrombolytic therapy (TT) i.e. IV tPA and endovascular thrombectomy (EVT).

Methods:
We analyzed the National Inpatient Sample (90% US hospitalizations) from 2006 - 2015 and identified adult (age ≥18) IS patients, with or without TT and PC using validated ICD-9 codes. We used survey design methods to report nationally representative adjusted odds ratios (aOR) of PC utilization across five 2-year time periods.

Results:
Of 4,249,201 IS encounters, 4% were coded for PC utilization. PC utilization increased over time (aOR 4.80, 95% CI 4.15 - 5.55), regardless of acute treatment type (Figure 1a). Advanced age, female sex, White race, non-Medicare insurance, higher income, disease severity and comorbidity burden, and discharge from teaching hospitals in non-Northeastern regions were independently associated with receiving PC. In the fully adjusted model, treatment with IV tPA and EVT respectively confer a 5% and 10% greater likelihood of receiving PC. Overall, PC utilization is associated with higher mortality (aOR 15.14, 95% CI 14.36 - 15.96). However, 10-year outcome trends demonstrate a significant decline in in-hospital mortality compared to all other dispositions (aOR 0.46, 95% CI 0.38 - 0.56) with an increasing proportion of PC patients receiving long-term care and home health/hospice (aOR 2.42, 95% CI 2.03 - 2.88) (Figure 1b). Despite longer length of stay, PC hospitalizations incurred 16% lower adjusted costs.

Conclusions:
Though PC utilization has increased in IS patients, considerable disparities exist. Acute TT is associated with higher PC utilization and outcome trends indicate lower in-hospital mortality with higher long-term care and home health/hospice. Protocolized PC for IS patients may optimize outcomes and costs.
Abstract WP365: Reducing Door-in-Door-out Times by Applying Failure Modes Effects and Criticality Analysis
Authors: Parnianpour Zahra , Khorzad Rebeca , Richards Christopher , Meurer William , Barnard Amy , Bader Elida , Hillmann Maureen , Zobel Rebecca , Hamilton Trevor , Knight Lacy , Holl Jane , Prabhakaran Shyam
Published: June 2021

Introduction:
Given the time-critical nature of acute stroke, reducing door-in-door-out (DIDO) times at primary stroke centers (PSC) prior to transfer to comprehensive stroke centers (CSC) is a priority. We applied Failure Modes Effects and Criticality Analysis (FMECA) to the DIDO process at a PSC, an engineering methodology widely used in other industries, to understand the most critical areas negatively impacting DIDO time.

Methods:
We collected data during 2 in-person and 5 virtual Learning Collaborative (LC) meetings, enhanced by electronic surveys. The LC team consisted of 18 clinicians affiliated with 6 different healthcare systems including 3 PSCs and 3 CSCs, 2 participants from EMS agencies, and 5 patients and caregivers. The LC team created a DIDO process map with individual steps. For each step, we asked LC members to identify ways in which the process could be performed incorrectly, incompletely, skipped or delayed (failures) along with the clinical impact, their causes, frequency and existing safeguards. Each clinical impact, frequency and safeguard was scored from 1-10 (lowest to highest). Frequency, severity, and safeguards scores were multiplied to calculate a criticality score to rank the top DIDO process failures.

Results:
Among 61 DIDO process steps, the top 12 steps with the highest criticality score represented 40.4% of the sum of criticalities (Figure). Among these, the highest criticality scores were for: 1) Delay in the decision to obtain CTA; 2) Delay in stroke recognition by the EMS team; 3) Delay in stroke identification at triage.

Conclusion:
We identified opportunities to re-design the DIDO process for acute stroke. Existing safeguards for the identified “high” criticality failures rely on human factors (e.g., multiple visual inspections, provider’s experience). There is a need to develop better stroke identification tools and automatic triggers within the DIDO process to increase timely stroke transfers from PSC to CSCs.
Abstract WP368: Evaluation of Brain Regional Characteristics Related With Post-Stroke Delirium Using Machine Learning and Statistical Analysis
Authors: Lee Seo Hyun , Hyon Yun Kyong , Yang Hee Won , Jeon Ki Wan , Jeon Ki Wan , Lee Miji , Ha Tae Young , Kim Jeong Lan , Lee Sukhoon , Kim Jei
Published: June 2021

Background:
The present study was performed to evaluate the brain regional characteristics related with development of post-stroke delirium using the machine learning and statistical analysis.

Method:
We used clinical and radiological data prospectively collected from 675 acute ischemic stroke patients, who were admitted in stroke unit from August 2017 to July 2018. Delirium occurrence in the patients was screened with Confusion Assessment Method and finally diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders (fifth edition). Three machine learning models, Support Vector Machine (SVM), Random Forest (RF) and Tree-based Gradient Boosting (XGBoost), were applied for the prediction of post-stroke delirium with the clinical and radiologic data. And logistic regression analysis was performed to evaluate the significance of the brain regional parameters included in the importance features which were obtained from the XGBoost result.

Results:
Post-stroke delirium occurred in 66 (9.8%) of the total patients. On the comparison of the test accuracy to predict delirium occurrence, RF (94%), XGBoost test (93%), and SVM (89%) showed similar prediction rates. Of the brain regional parameters included in the top 30 feature importance, right side cerebral hemisphere, non-lacunar infarction, severity of periventricular white matter changes, acute temporal lobe lesion, cerebellum, brain stem, and previous lesions developed on right side cerebral hemisphere, and in temporal or frontal lobe.

Conclusion:
The present study shows that the brain regional characteristics related with the post-stroke delirium are shown to be significant when controlling the other features using statistical analysis with machine learning. Even though we need more studies to validate the relationships between post-stroke delirium and brain regional characteristics, the present brain regional characteristics could provide significant evidences to predict post-stroke delirium for the acute ischemic stroke patients.
Abstract WP381: Modafinil in Recovery After Stroke: A Retrospective Study
Authors: Cross Danielle B , Tiu Jonathan , Medicherla Chaitanya , Ishida Koto , Lord Aaron , Czeisler Barry , Zhang Cen , Lewis Ariane , Wu Christopher , Karoub Amabel , Golub Danielle , Hernandez Christopher , Yaghi Shadi , Torres Jose
Published: June 2021

Background:
Acute rehabilitation is known to enhance stroke recovery. However, post-stroke lethargy and fatigue can hinder participation in rehabilitation therapies. We hypothesized that in patients with moderate to severe stroke, early stimulant therapy with modafinil increases favorable discharge disposition defined as transfer to acute rehabilitation.

Methods:
We retrospectively reviewed a cohort of patients with acute stroke admitted over a 3 year period. Patients were excluded for low NIH Stroke Scale score (below 5) or absence of confirmed stroke on brain imaging. We compared patients that were treated with modafinil 50-200mg to those managed with standard care. The primary outcome measure was discharge disposition. Secondary outcome was modified Rankin Score after discharge. Statistical significance was determined using chi-square test for association and logistic regression models.

Results:
The study cohort included 199 patients (145 ischemic, 54 hemorrhagic). 72 (36.2%) were treated with modafinil and 129 (64.8%) were discharged to acute rehab. Median NIHSS for modafinil patients vs standard care patients was higher but did not reach statistical significance (median (IQR): 13.5 (15) vs 11 (10), p=0.059). In adjusted models, modafinil was associated with higher odds of favorable discharge disposition (OR 2.00, 95% CI 1.01-3.95). Favorable outcome at 90 days (mRS ≤ 2) occurred more frequently with modafinil (5.6% vs. 3.3%) but this did not achieve statistical significance (p>0.1). The benefit of modafinil was seen across all subgroups of patients, except those with severe stroke (NIHSS
>
15). There were no significant complications clearly linked to modafinil administration.

Conclusions:
Modafinil use in acute stroke patients with moderate to severe stroke was associated with improved discharge disposition. Randomized controlled trials are needed to further study the safety, efficacy, and long-term effects of modafinil in this population.
Abstract WP387: Race and Sex Differences in Long Term Cognitive Impairment Among Delirious Patients With Acute Neurological Injuries: A Population Based Study
Authors: Kumar Aditya , Bambhroliya Arvind , Meeks Jennifer R , Zha Alicia , Sheth Sunil A , McCullough Louise D , Savitz Sean I , Vahidy Farhaan S
Published: June 2021

Background:
Higher incidence of mild cognitive impairment and dementia (MCID) has been reported in patients with acute neurological injuries (ANI) who are exposed to in-hospital delirium. However, race and sex differences for delirium associated MCID have not been described.

Methods:
We analyzed State Inpatient and Emergency Department Databases for NY, FL and CA (2006 - 2014) for four categories of adult (≥18) ANI patients (ischemic stroke, intracerebral hemorrhage, sub-arachnoid hemorrhage and traumatic brain injury). Delirium and MCID were tagged using validated diagnostic codes. Patients diagnosed with MCID prior to or within 90-day after ANI event were excluded. We performed time-to-event analyses to explore race and sex differences in development of MCID among delirious ANI patients. Interaction of sex and race with age was also examined. Hazard Ratios (HR) and 95% CIs are reported.

Results:
We identified 911,380 eligible ANI patients of whom 5.4% were documented to have delirium. After excluding patients without follow-up, we analyzed a total of 34,990 ANI patients with initial in-hospital delirium, among whom 11.5% subsequently developed MCID. In the fully adjusted multivariable model, males had a higher risk of developing MCID (HR, 95% CI: 1.09, 1.01 - 1.16). African Americans, Hispanics and patients in other racial groups also had a higher independent risk of developing MCID, as compared to Caucasians. (Figure 1a). The interaction between age and sex was statically significant (p = 0.04), indicating higher risk of incident MCID among males with increasing age as compared to females. This difference was pronounced beyond 65 years. (Figure 1b).

Conclusions:
Certain demographic groups hospitalized for ANI may be differentially susceptible to the risk of long-term cognitive decline associated with in-hospital delirium. Targeted and personalized strategies for the early identification and management of delirium during hospitalization may be warranted.
Abstract WP389: Anatomical Trajectory for Focused Ultrasound Stimulation of Fastigial Nucleus for Neuroprotection in Human Cerebral Ischemia
Authors: Bahr Hosseini Mersedeh , Spivak Norman , Monti Martin , Korb Alex , Saver Jeffrey L
Published: June 2021

Introduction:
In multiple animal models of ischemic stroke, cerebellar fastigial nucleus stimulation (FNS) via implanted electrode has been shown to exert strong neuroprotective and collateral enhancement effects. Translational studies of FNS have been precluded due to the invasive nature of direct electrical stimulation. Recently, low-intensity focused ultrasound pulsation (LIFUP) has been used to stimulate deep hemispheric targets. Identifying achievable anatomic trajectories for LIFUP delivery is required for human trials.

Method:
Sagittal brain MRI T1 from 10 patients were analyzed. Potential pathways from the suboccipital (SO) region (transducer placement site) to the roof of the 4
th
ventricle (location of FN) were traced, evaluating paths both via the thinnest portion of the occipital bone (OB) and via the transforaminal window (TFW). Interindividual variations in trajectory distances (cm), thickness of the OB through which the beam passes (cm), and the projected neck flexion degree from neutral position required to achieve a TFW path were measured.

Results:
An achievable anatomic pathway for stimulation of the FN via LIFUP was identified in 100% of patients (Fig 1). In standard MR positioning, 90% had an available path through thin portions of the OB and 10% had a projected path through TFW. The mean distance from the skin at the SO region to the roof of 4
th
ventricle/FN was 7.2 cm (± 0.64cm). The mean OB thickness traversed by the beam was 0.3cm (±0.1). The projected required neck flexion to enable a TFW in all subjects was mean 9.3° (±5°).

Conclusions:
The distance for the LIFUP beam to travel from skin surface to FN via a suboccipital approach is well within the LIFUP penetration depth and all individuals had an accessible trajectory via the TFW through attainable degrees of head flexion, affording minimal ultrasonic energy dispersion and maximal focality. Ultrasound stimulation of fastigial nucleus is a feasible treatment strategy in human acute ischemic stroke.
Abstract WP397: Longitudinal Sex Differences in Cerebral Amyloid Angiopathy
Authors: Maniskas Michael , Hudobenko Jacob , Urayama Akhiko , McCullough Louise , Manwani Bharti
Published: June 2021

Background:
Cerebral amyloid angiopathy (CAA) is the most common cause of lobar intracerebral hemorrhage in the aging population. It is mostly a consequence of amyloid beta40 (Aβ40) deposition within the cerebral blood vessels. A recent study has shown that this amyloid plaque deposition is more prevalent in the brain of elderly women compared to men. The increase in amyloid plaque deposition is linked to increased cerebral microbleeds (CMBs) and reduced cognition. The major objective of this study to discern if a sexual dichotomy existed in CMBs and cognition using mouse model of CAA.

Methods:
We used the Tg-SwDI mouse (“CAA mouse”, harboring Swedish, Dutch, and Iowa mutations of human amyloid precursor protein) model that develops Aβ deposits and cognitive deficits at 3-4 months. Cognitive deficits were analyzed using Fear Conditioning (FC) in pre-symptomatic (3 month) and (12 month) old male and female mice. Briefly, mice were acclimated to the FC chamber for a 2 minute training trial to record baseline. After 1 hour rest, mice were placed back in the chamber for 2 minutes, where they received a 2 millisecond shock (1,000 u/amp). Day 2, activity was recorded for 3 minutes and this measure was compared to baseline to determine Mean Inactive State (MIS-seconds). Mice were euthanized following FC, and brains scanned
ex vivo
using a MRI T2 Star sequence to assess for CMBs.

Results:
FC showed a significant difference in MIS (p<0.05) between male (3 and 12 months old) and female (3 months only) mice, n=6/group, suggesting that aged females had significantly lower MIS (Figure 1). MRI showed that aged female mice had more CMBs compared to aged male mice (females, 15.3±7 vs. males 0.25 ±0.2, n= 3/group, p=0.05.

Conclusion:
In a mouse model of CAA, our results demonstrate that aged females have increased CMBs as compared to males, which may be contributing to decreased cognition as seen on FC. Ongoing studies are designed to further understand the etiology of this sex difference.
Abstract WP400: Causes of Death in a Longitudinal Analysis of Spontaneous Intracerebral Hemorrhage Survivors
Authors: Kuohn Lindsey R , Leasure Audrey C , Acosta Julian N , Vanent Kevin N , Murthy Santosh B , Kamel Hooman , Matouk Charles N , Sansing Lauren H , Falcone Guido J , Sheth Kevin N
Published: June 2021

Introduction:
With improvements in acute care, more patients are surviving a first-time spontaneous intracerebral hemorrhage (ICH). In the growing survivor population, little is known about effective secondary stroke prevention strategies or long-term causes of illness and death. This study aims to determine the cause of death in first-time ICH survivors.

Methods:
We performed a longitudinal analysis of prospectively collected claims data. We used data collected on all hospitalizations from California (2005-2011) and New York (2005-2014). State residents admitted with a primary diagnosis of non-traumatic ICH (ICD-9-CM code 431) who survived to discharge were included in the study. Patients were followed for a primary outcome of any readmission event resulting in death. Cause of death was defined as the primary diagnosis assigned at discharge. Kaplan-Meier survival analysis was used to estimate the risk of in-hospital death during follow-up. Cox proportional hazards and multinomial logistic regression were used to determine factors associated with the risk and cause for death. Subgroup analyses stratified by a history of atrial fibrillation (AF) were performed.

Results:
Of 56,593 identified ICH survivors (mean age 69 [SD 15], 49% female), 6,931 (14%) died during a median follow-up period of 3.6 years (IQR 1.5-5.9). The one-year risk of death was 7% (95% CI 7.0-7.4) and the median time to death was 0.7 years (IQR 0.1-2.3). Patients who died were older (74 vs. 68, p<0.001) and more likely to have history of AF (24% vs. 16%, p<0.001), congestive heart disease (15% vs. 8%, p<0.001), and diabetes (32% vs. 26%, p<0.001). The leading causes of death were infection (29%), recurrent ICH (12%), cardiac causes (8%), respiratory failure (7%), and ischemic stroke (4%). Patients with AF were at an increased the risk of death from ischemic stroke (OR 2.04, 95% CI 1.56-2.68, p<0.001) and cardiac causes (OR 1.49, 95% CI 1.19-1.87, p=0.002) compared to those without AF.

Conclusions:
The leading causes of inpatient death in ICH survivors are infection, recurrent ICH, and cardiac causes while survivors with AF are at an elevated risk for death by recurrent stroke. These findings may represent interventional targets in the effort to extend improved outcomes in ICH survivors.