bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract T P318: Impact of Pre-stroke Sulphonylurea and Metformin Use on Outcome of Intracerebral Hemorrhage
Authors: Wu Teddy , Campbell Bruce , Strbian Daniel , Yassi Nawaf , Putaala Jukka , Tatlisumak Turgut , Davis Stephen , Meretoja Atte ,   VISTA-ICH Collaboration
Published: March 2022

Background and Purpose:
There is currently no effective treatment for intracerebral hemorrhage (ICH). Preliminary evidence suggests sulphonylurea may be protective in ischemic stroke. Metformin reduced post stroke lactate generation in an animal model. Our objective was to assess the effects of sulphonylurea and metformin use at time of stroke onset on ICH outcome.

Methods:
We merged patient data from the consecutive single-center Helsinki ICH Study and the ICH arm of the pooled repository of trials Virtual International Trials Archive (VISTA-ICH). Logistic regression adjusting for known predictors of ICH outcome estimated the association of pre-stroke exposure to metformin and sulphonylurea with all-cause 90-day mortality. Ordinal shift analysis for 90-day mRS was performed with the same covariates in the VISTA dataset only.

Results:
After excluding cases with missing data (n=190) we included 1810 patients (Helsinki n=961, VISTA-ICH n=849), of whom 478 (26%) died by 90 days. Of the 289 (16%) diabetic patients, 100 (34.6%) used metformin and 78 (27%) sulphonylurea at ICH onset. After adjusting for age, sex, baseline GCS, NIHSS, volume, infratentorial location, intraventricular extension, and pre-ICH warfarin use, there was no association with sulphonylurea (OR 1.22; 95% CI 0.63-2.40;p=0.55) or metformin (OR 0.69;0.36-1.33;p=0.27) use with 90-day mortality. When restricted to the diabetic subgroup, metformin use was associated with lower 90-day mortality (OR 0.44;0.20-0.97;p=0.041) while sulphonylurea was not (OR 0.90;0.41-1.96;p=0.79). In the ordinal shift analysis neither metformin nor sulphonylurea influenced 90-day mRS in the whole dataset (p>0.5), although in the diabetic subgroup there was a trend towards improved outcome with metformin use (0.7 point reduction;-0.1-1.5;p=0.09). Conclusion: Sulphonylurea or metformin use at time of stroke was not associated with outcome in all ICH patients but there was a signal of lower mortality and possibly improved functional outcome with metformin use in diabetic patients. The protective effect of metformin might be a result of improved glycemic control or reduced lactate generation. Our results generate hypotheses which after further validation may be tested in clinical trials.
Abstract T P320: Clinical Relevance of Cerebral Microbleeds in Patients with Atrial Fibrillation and Stroke
Authors: Haji Shamir , Zubair Adeel , Planchard Ryan , Flemming Kelly
Published: March 2022

Background:
Cerebral microbleeds (CMB) incidentally found during an MRI evaluation of ischemic stroke present a therapeutic dilemma. Case control studies suggest a relationship of cerebral microbleeds and intracerebral hemorrhage. Limited prospective studies of patients with ischemic stroke show variability in whether CMB hemorrhage rates are greater than recurrent ischemic stroke rates. Our aim was to determine the prevalence and characteristics of CMB in patients with atrial fibrillation presenting with stroke and secondly what the rate of prospective intracerebral hemorrhage (ICH) was in those same patients.

Methods:
Consecutive patients admitted with atrial fibrillation and stroke were identified in our institution’s Get with the Guideline database between 2008-2009. Data from the incident hospitalization included: demographic information, use of antithrombotic and/or anticoagulation, and cerebrovascular risk factors. Radiologic imaging was reviewed to determine if a GRE or SWI sequence was included and record the number and location of CMB. Follow up information was obtained by chart review and written survey or phone call. Death certificates were obtained where applicable.

Results:
240 patients were identified, 128 of whom had a CT only and 112 who had an MRI. Of those with an MRI, 76 had GRE or SWI sequences. Twenty-one of 76 patients with a GRE or SWI sequence had a CMB (prevalence: 27.6%). One patient in the CMB (+) group had a prospective hemorrhage during an average follow up of 3 years (rate: 0.33 ICH per patient year of follow up). No patients in the CMB negative group had an ICH.

Conclusions:
Our study demonstrates the prevalence of cerebral microbleeds is much higher than the actual prospective hemorrhage rate. The prospective hemorrhage rate is low and consistent with findings from large, randomized anticoagulation studies in patients with atrial fibrillation.
Abstract T P322: Risk Factors for Vascular Lesions as Etiology of Intraventricular Hemorrhage in Prospectively Screened Cases
Authors: Pang Alice , Mayo Steve , Stadnik Agnieszka , Jesselson Michael , Zhang Lingjiao , Dlugash Rachel , Hanley Daniel , Awad Issam
Published: March 2022

Introduction:
Previous studies have used inconsistent screening thresholds and modalities for detecting vascular lesions as the cause of intraventricular hemorrhage (IVH). We aimed to characterize demographic and ethnicity risks of harboring vascular lesions in a cohort of prospectively identified IVH cases with systematic screening for underlying vascular etiology.

Methods:
Patients with IVH were identified from the database of Clot Lysis: Evaluation Accelerated Resolution of Intraventricular Hemorrhage Phase III (CLEAR III) clinical trial. It included patients age 18-80 years with obstructive IVH with or without associated intracerebral hemorrhage (ICH) less than 30 ml in volume. This cohort study compared 447 patients enrolled in CLEAR, who were screened negative for underlying vascular lesion (no lesion), and 1276 patients with IVH concurrently screened and excluded from CLEAR because of underlying lesion (vascular lesion).

Results:
Mean age was lower in patients with vascular lesion (55 vs. 59; p<.001), with a greater difference in patients with vascular malformations (47 versus 58, p<.001) and Moyamoya disease (45 versus 58, p<.001), and there was no difference in age of patients with aneurysms versus no lesion (mean age 59 in both groups). Male prevalence was lower (lesion: 42%, no lesion: 55%; p<.001), with a higher prevalence in those with vascular malformations than those with aneurysm (56% versus 35%, p<.001) and Moyamoya disease (56% versus 39%, p=0.074). The prevalence of Whites was higher (lesion: 60%, no lesion: 51%; p<.001) and that of African-Americans lower (lesion: 11%, no lesion: 33%; p<.001). The prevalence of patients with primary IVH as opposed to IVH with intracerebral hemorrhage (ICH) was higher among patients with lesions (lesion: 21%, no lesion: 15%; p=.003).

Conclusion:
IVH patients with an underlying vascular lesion tend to be significantly younger, more likely female, White, and harbor primary IVH. The younger age is attributed to vascular malformations or Moyamoya disease, rather than aneurysm. Patients with lesion may have exhibited other characteristic features of hemorrhage not addressed in this study.
Abstract T P326: The Utility of Charlson Comorbidity Index in Predicting Short-term Outcomes in Patients with Primary Intracerebral Hemorrhage
Authors: Khawaja Ayaz , Boehme Amelia K , Albright Karen , Kumar Gyanendra , Arora Kanika , Lyerly Michael , Harrigan Mark
Published: March 2022

Background and Purpose:
The Charlson Comorbidity Index (CCI) is used to evaluate a patient's risk of in-hospital, 1-year and 10-year mortality, and has been validated in acute ischemic stroke. Previous studies have shown that CCI influences functional outcomes. We sought to evaluate the association between CCI and outcomes in patients with primary ICH presenting to our center.

Methods:
Patients with primary ICH admitted to our center from 2008-2013 were included. Demographic and clinical data were collected. Primary outcomes were a discharge mRS (dmRS) of 4-6, death and poor discharge disposition (any disposition other than home or inpatient rehabilitation). Crude and adjusted logistic regressions were used to evaluate the association between CCI and outcomes.

Results:
A total of 383 patients were identified. There were 37 (9.7%) patients with a CCI of 0 or 1, 242 (63.2%) patients with a CCI of 2-5, and 104 (27.2%) with a CCI of 6 or greater (Figure). While the continuous CCI was not significantly associated with a dmRS of 4-6 (OR 1.08, 95% CI 0.99-1.19, p=0.09), it was associated with disposition. The odds of poor disposition increased 18% with each increase in CCI (OR 1.18, 95% CI 1.08-1.28, p=0.0003). The odds of death increased 12% with each point increase in CCI (OR 1.12, 95% CI 1.02-1.23, p=0.021). After adjusting for baseline ICH score, CCI remained significantly associated with poor disposition (OR 1.13, 95% CI 1.00-1.27, p=0.042), however the association between CCI and death was not statistically significant (OR 1.05, 95% CI 0.91-1.21, p=0.52).

Conclusions:
In contrast to previous studies, the CCI was not associated with poor short-term functional outcome or in-hospital mortality. However, it was significantly associated with poor discharge disposition. This suggests that cumulative comorbidities only predict disposition in ICH, because the ICH score strongly impacts poor functional outcome and in-hospital mortality.
Abstract T P328: Patients with Low NIHSS Stroke Scales Have Longer Door to Needle Times: An Analysis of a Telestroke Network
Authors: Bhatt Archit , Lesko Alexandra , Kansara Amit , Baraban Elizabeth
Published: March 2022

Background:
The benefits of intravenous tissue-type plasminogen activator (IV tPA) in acute ischemic stroke are time dependent. We hypothesized that patients with lower stroke scales would have longer door to needle times (DNT), in addition to other time dependent measures, compared to patients with higher stroke scales because emergency rooms more readily start a stroke alert with more severe symptoms.

Methods:
Data obtained from the 17-partner hospital Providence stroke registry was used to identify AIS (Acute Ischemic Stroke) patients who received IV tPA within 4.5 hours of symptom onset. NIHSS stroke scores were abstracted prior to tPA administration at the time of ED presentation and categorized into 0 through 5 and 6 through 42, as minor and non-minor strokes respectively. Mean DNT were collected for both groups as the primary outcome variable. Analysis of variance was performed to assess differences in DNT, door to CT (DCT) and door to physician evaluation (DPE) between the minor and non-minor NIHSS groups.

Results:
A total of 131 AIS patients who received IV tPA within 4.5 hours of symptom onset were identified. Among those, 22 patients presented with a NIHSS ≤ 5 (minor) and 109 patients with a NIHSS > 5 (non-minor). Patients with minor strokes had significantly higher mean DNT times (67.9 ±11.7minutes) compared to those with non-minor strokes (61.2± 13.6 minutes), (p=.036). Mean DCT times were not significantly different between minor ( 17.3 ± 9.5 minutes) and non-minor ( 15.2± 8.3 minutes) strokes, (p=.321). Mean DPE was also not significantly different between minor (4.8±4.7 minutes) and non-minor (4.3 ± 5.0 minutes) strokes (p=.791).

Conclusion:
In patients receiving IV tPA for ischemic stroke in a telestroke network, having lower NIHSS stroke scale was associated with longer DNT. Further analysis with a larger sample is needed to determine if other factors impact this association.
Abstract T P33: Separating Acute Infarct Core From Penumbra Using Optimized Imaging And Standardized Post-processing In The Setting Of Ischemic Stroke: A CT Perfusion Study
Authors: d'Esterre Christopher , Qazi Emmad , Patil Shivanand , Fainardi Enrico , Rubiera Marta , Khaw Alex , Lee Ting-Yim , Almekhlafi Mohammed , Frayne Richard , Demchuk Andrew M , Goyal Mayank , Menon Bijoy
Published: March 2022

Background:
In the setting of acute ischemic stroke, CT Perfusion (CTP) may change thrombolytic/endovascular treatment decisions when compared to NCCT/CTA alone. Two distinct thresholds may be useful in this regard: separation of 1) non-salvageable tissue (infarct core) from salvageable electrically silent tissue (penumbra), and 2) penumbra from benign oligemia (hypoperfused, but will survive if clot persists).

Methods:
CTP (120s,8cm) was performed on 180 patients within 12hrs of ischemic stroke. Two patient cohorts were analyzed: (1) recanalization (TICI 2b,3) 6s. For group (2) CBF, CBV, and Tmax values were obtained from within the final infarct region, and total ipsilateral hemisphere, excluding infarction. CBF, CBV and Tmax were used in univariate regression models.

Results:
For group (1)[n=11], mean time from CTP to recanalization was 60±19min. CBF parameter (thresholds for gray and white matter 7.2 and 5.2 ml•min-1•(100g)-1) had the highest sensitivity (90.9%) and specificity (81.8%) for infarction. For group (2)[n=15], the Tmax parameter (thresholds for gray and white matter 11.3s and 11.8s) had the highest sensitivity (86.6%) and specificity (80.0%) for penumbra.

Conclusion:
CTP thresholds derived from ultra-early reperfusers could potentially best define what is clinically dead in patients with acute ischemic stroke
Abstract T P332: Stroke Patient Education -A Story of Improvement
Authors: Daansen Patricia A , Beauchamp Joan , Wood Cheryl
Published: March 2022

Background:
Rochester General Hospital (RGH) is a 559 bed acute care community hosp. in Rochester, N.Y. Designated as a Stroke Center in 2003, the Hosp. discharges 850 stroke & TIA pts. annually.

The Stroke Coalition Team consists of members of the stroke pt. care areas & supporting depts. Group's purpose- provide a collaborative forum for sharing outcomes to improve stroke care.

Each dept. has a core group to review actionable data for their areas. The Acute Stroke Unit (7800) Team’s purpose is to act on unit process improvement opportunities.

May 2013- a negative trend with the Core Measure for pt. education was identified for the Coalition group. As a result, the 7800 leaders began investigating for root cause.

Purpose of this QI program was to assure all pts. receive designated pt. education and documentation is complete. A secondary purpose was to improve the quality of the education.

Methods:
Four main barriers were identified:

1. RNs not understanding expectations

2. Novice RNs not comfortable in educating pts. and families

3. Electronic Medical Record (EMR)complexity - launched 11/12

4. Education complete but lacking documentation

Action plan:

1 & 2. RN education

A.Self-learning packet (SLP) that included:

• Requirements of pt. education

• How to document the education

B. 1:1 support from CNS & Nurse Manager

C. Daily chart audits to ID further opportunities & barriers to compliance

D. RNs educated on teaching tools:

•Welcome binder

• AHA/ASA brochures for Stroke/TIA/diagnostic tests

• Pt. educational TV offerings

•Medical/nursing database

3. Complexity of EMR- Collaborated to make changes to the EMR templates.

A. Automatic entry of the education template upon stroke order set

B. Required education flagged

C. Individualization of pt. education

D. Standardized admission & discharge nursing notes

4. Lack of Documentation

A. Discharge checklists made available

B. Chart compliance audits (decreasing to random as compliance rose)

Results:
Rapid turn-around achieved. Recognized as best practice by Joint Commission during the Center’s 3/2014 re-designation.

Conclusion:
Rapid improvement possible with action upon data. Team approach allows for appropriate action to occur.

Efforts continue to enhance compliance & pt. experience.
Abstract T P336: Pursuit of Door to Needle Reductions through Enhanced Partnerships: A Paradigm Shift
Authors: Small Cristine W , Freeman Susan D , March Juan A , Foss Angela K , Bogenn Frankie , Landry Bob , Price Donald L , Cogdell Vonda L
Published: March 2022

Purpose:
Ischemic stroke patients, who meet criteria to be administered t-PA, should receive a patient-focused effort that advocates for quality, efficacious treatment. It’s essential to continuously evaluate the impact that a model of care delivery has on clinical outcomes. Healthcare reform may dictate utilization of current resources and often allocation of those resources are re-aligned to meet financial targets. The model of care delivery referenced in this study includes primary responders on a code stroke team that have transitioned from a unit based resource to an emergency room resource. Quality outcomes are a priority and overcoming obstacles to prevent delays in meeting the national benchmark of door to needle time in less than 60 minutes requires enhanced partnerships. The purpose of this study was to determine the effects that a model of care delivery for acute stroke response had on door to needle time and identify the impact from utilization of value stream mapping.

Methods:
Retrospective chart reviews were conducted on stroke patients that received t-PA over a 5 year period. Comparative analysis of all response times were reviewed for trends and opportunities that may have also been impacted by the model of care delivery. Immediate review and feedback on every case served as a catalyst for quality improvement, engaging all providers to implement changes that would improve door to needle times. Response time data was analyzed to determine if there was statistical significance, such that all opportunities for improvement to reduce needle to door time to < 60 minutes could be addressed with action plans.

Results:
Percentage compliance of door to needle time within 60 minutes increased from 17% to 63% during the study period.

Opportunities to further reduce door to needle times reveal potential decrease of key response times by approximately 20 minutes. This is evidenced by continued improvement in the average door to needle time by 15 minutes during the study period.

Conclusion:
Transition of care delivery models with ownership and team engagement can result in a paradigm shift that indicates effective action plans for quality improvement in door to needle times. Further insight from value mapping serves as a guide for lean processes.
Abstract T P34: Poor Collateral Circulation Assessed By Multiphase Cta Predicts Malignant Mca Evolution After Reperfusion Therapies
Authors: Flores Alan , Rubiera Marta , Ribó Jacobi Marc , Pagola Jorge , Rodriguez-Luna David , Muchada Marian , Boned Riera Sandra , Seró Ballesteros Laia , Meler Pilar , Sanjuan Stela , Cárcamo Daniel , Santamarina Estevo , Tomasello Alejandro , Coscojuela PIlar , Lemus Miguel , Carvalho Vanessa , de Bonadona David , Ponciano Rafael , Menon Bijoy , Goyal Mayank , Molina Carlos A.
Published: March 2022

Background:
Collateral circulation (CC) has been associated with recanalization, infarct volume, risk of haemorrhagic transformation and clinical outcome in patients undergoing acute reperfusion therapies. However, its relationship with the development to malignant MCA infarction (mMCAi) has not been evaluated. Our aim was determine the impact of collateral circulation using multiphase CTA (mCTA) on acute phase in the prediction of mMCAi.

Methods:
Consecutive acute stroke <4.5h patients that were evaluated for reperfusion therapies and with a M1-MCA or TICA occlusion by CTA were included. CC was evaluated on mCTA, CC evaluation was performed according to the University Calgary CC Scale; CC was also classified as poor (grades 0-3) or good (grades 4-5). The mMCAi was defined according to previously published clinical and radiological criteria. Recanalization was assessed with TCD at 24-hours and TICI score≥2a in endovascular treatment (ET) patients. Good outcome was defined as mRS 0-2 at 3months.

Results:
82 patients were included. Mean age: 65.1 ±13.83 years, median baseline NIHSS 18(IQR 5.7), 67.9% M1 and 32.1% TICA occlusions, 53 patients received ET and 57 iv tPA, 15 patients develop a mMCAi. In the univariate analysis, patients with mMCAi had lower CC scores (2.29 Vs. 3.71 p=0.001), higher baseline NIHSS (19.86 Vs. 15.70 p=0.016), lower TIMI reperfusion scores (0 Vs. 2.79 p=00.5) and presence of TICA occlusion was more often compared with M1 occlusion (71% Vs. 11.9%, p=0.033) ET was associated with lower rate of mMCAi development as compared with only i.v. reperfusion treatment (9.4%Vs.29.6%, p=0.028). Furthermore, all patients with poor CC who did not recanalize developed mMCAi (6 Vs. 0, p=0.68) On the multivariate analysis adjusted to age, vessel occlusion, baseline NIHSS and recanalization, the presence of poor CC by mCTA was the only independent predictor of mMCAi (p=0.048 OR: 9.72, 95%IC: 1.387-92.53)

Conclusion:
CC assessment by mCTA independently predicts malignant MCA progression. In patients with persistent occlusion after reperfusion therapies, the presence of poor CC may help in the early malignant MCA detection and management.
Abstract T P340: The Electronic Medical Record: Are the Times Accurate?
Authors: Lawrence Erin , Woolford Cheryl , Merbach Dawn , Thorpe Sherry , Llinas Rafael H , Marsh Elisabeth B
Published: March 2022

Background:
The Electronic Medical Record (EMR) was designed to improve patient outcomes, eliminate unnecessary costs, and provide continuity of care. Intravenous tissue plasminogen activator (IV t-PA) is most effective when administered early. In order to effectively decrease door to needle times, a stroke center must be able to correctly identify the steps within their pathway where there is room for improvement. A reliable way to measure and record time is therefore crucial. In our experience, the EMR has been extremely helpful with data collection; however, there are limitations, particularly with respect to the automatic time stamp for electronic documentation. We sought to determine the accuracy of the EMR time stamp versus real-time paper charting in our assessment of the acute stroke patient.

Methods:
33 patients treated with IV t-PA between July 2013 and July 2014 were included in analysis. Specific time points were documented on a Nursing Flow Sheet by a dedicated stroke nurse who is part of each acute stroke assessment and were compared to the time points documented in the EMR. The average discrepancy between the Nursing Flow Sheet and EMR for each time point was calculated. Arrival time to the Emergency Department (ED), time to CT scanner, lab collection time, and t-PA bolus time were evaluated.

Results:
The average discrepancy on arrival time to the ED was 7 minutes. The Nursing Flowsheet documented earlier arrival times in all but 2 cases. The arrival time obtained from the EMR required extrapolation- either from the point of comprehensive triage where vital signs were obtained (n=24) or from the code sheet scanned into the electronic record (n=9). Times documented on the code sheet were only 3 minutes different from the Nursing Flow Sheet versus 9 minutes for those with vital signs charted. The average discrepancy between time to the CT scanner on the Nursing Flow Sheet and the order time in the EMR was 13 minutes. The majority of patients (88%) had imaging completed prior to the order being placed. The discrepancies for lab collection time and t-PA bolus time were smaller (4 minutes and 0 minutes respectively).

Conclusion:
Automatic time stamps provided by an EMR may not accurately reflect true time points, making improvement of door to needle times more difficult.
Abstract T P350: Bridging The Gap Between Acute Care and Public Health
Authors: Moore Kari D , Bobo Bonita , Greer Destiny , Lee Jamie , Wise Elizabeth
Published: March 2022

Background:
The WHO estimates that only 50% of patients with chronic illness adhere to treatment recommendations. The Affordable Care Act targets hospital readmission rates as cost savings opportunities. Transitional care programs have been shown to improve patient outcomes.

Purpose:
To reduce readmission and recurrent stroke, the Stroke Patient Education and Navigation (SPEN) Pilot Project sought to enhance the continuum of care post discharge by forming collaboration between the University of Louisville Stroke Center (ULSC), Taylor Regional Hospital (TRH) and the Department for Public Health. Primary outcomes of this one-year pilot were hospital readmission rate, medication compliance, and utilization of community resources.

Methods:
Stroke patients transferred from TRH to ULSC discharged home were invited to participate. Upon d/c home nurses made three home visits (2 weeks, 3 months, and 6 months post discharge) to assess outcomes and to obtain demographics, PCP, whether patient was receiving rehab, mRS score, BMI, vital signs, labs, vascular risk factors, patient/caregivers’ ability to measure their own blood pressure, verbalize stroke symptoms, behavioral modifications since hospital discharge, and self assessment of perceived health status.

Results:
21 patients agreed to participate in SPEN, 3 of whom did not complete the study. The average time per 1
st
, 2
nd
, and 3
rd
nurses’ visits were 4 hours, 3.2 hours, and 2.9 hours respectively. The total cost of 56 health department home visits, including travel and expenses was $12,219.02, a cost per home visit of $218.20. The cost per patient for the project was $581.86. 95.2% adhered to their medications as prescribed. No patients were readmitted to the hospital within 30 days. Only one person (4.8%) participated in a community resource, a smoking cessation program at the health department. Most sited that they did not utilize community resources due to lack of transportation.

Conclusions:
SPEN results revealed excellent medication compliance, no hospital readmissions within 30 days, but low community resource utilization. The sample size was small and limited to six -month follow up. Further outcomes and cost analyses can be obtained with a larger sample size and extended follow up.
Abstract T P378: Factors Associated with the Presentation of Moyamoya in Childhood
Authors: Amlie-Lefond Catherine , Amlie-Lefond Catherine
Published: March 2022

Introduction:
Moyamoya accounts for approximately one fifth of cerebral arteriopathies in children presenting with acute stroke, however often is not diagnosed until stroke occurs, even in higher risk populations and often despite a history of transient ischemic attacks (TIA’s). The surgical management and outcome are well reported, but limited information exists regarding signs and symptoms preceding diagnosis. This study was undertaken to better define which groups of children are at risk for moyamoya and how these children present.

Methods:
With IRB approval, the charts of all patients with a diagnosis of moyamoya cared for between Jan 1, 1997 - Sept 26, 2013 were reviewed.

Results:
Of 54 children with moyamoya, the mean age at presentation was 7 ½ years. 56% were female. 32 (59 %) had predisposing medical conditions associated with moyamoya. 17 (31%) were of Asian descent. Only 11 children (20%) had no underlying predisposing condition identified, of whom 4 had underlying conditions not previously reported in association with moyamoya. 8 patients (15%) were Native American. 38 (70%) had a history of transient ischemic attacks. 26 (48%) presented with acute stroke, of whom ¾ had left and ¼ had right hemisphere strokes. 52% had a history of headache.

Discussion:
The mean age and female predominance in this series are consistent with previous reports. Most children with moyamoya in this series had an underlying predisposing condition, compared with other US series, where almost half had no predisposing condition identified. 15% of children in this series are American Indian or Alaska Native, compared with 1.3% of all patients served at this institution. In this series, fewer children (48% vs 68%) presented with stroke, more (70% vs 43%) had a history of TIAs, and more (52% vs 22%) had a history of headaches than in previous reports. In addition, the Native American population may be at higher risk of moyamoya than previously recognized.
Abstract T P384: Development of a Screening Tool for Obstructive Sleep Apnea in the Stroke Population
Authors: Katzan Irene , Thompson Nicolas , Uchino Ken , Foldvary Nancy
Published: March 2022

Background:
Obstructive Sleep Apnea (OSA) occurs in >50% patients with stroke/ TIA; treatment can improve outcomes. Current OSA screens do not perform well in stroke patients. The objective of this study is to develop an OSA screening tool for use in stroke patients.

Methods:
The cohort consisted of patients seen in a cerebrovascular clinic who completed the STOP survey Jan 2011 - Dec 2012 and underwent polysomnography (PSG) for OSA within 1 year. The STOP tool, a commonly used OSA screen, served as the base model to enhance. Six prediction models were created. The dependent variable was presence of OSA (defined by AHI ≥ 10) identified on PSG. The predictor variables, in addition to STOP items, were based upon lit review and electronically extracted from the EHR, except for neck circumference which was recorded at the time of the PSG. Receiver operating characteristic (ROC) curves were created and sensitivity and specificity of various cutoff scores were calculated for each model. Validation was done using bootstrap methods with 200 iterations.

Results:
There were 208 patients in cohort with mean age 55.4 yrs, 49.0% were female. Sleep apnea was diagnosed in 61.0%. ROC curves for the models are displayed in the Figure. Models with the highest c-statistics included BMI, age and gender, plus the STOP items (STOP-BAG). Addition of neck circumference and other variables did not significantly improve the models.

The STOP-BAG2 model, using continuous variables, had a sensitivity of 0.94 (95% 0.89-0.98) and specificity 0.60 (95% CI 0.49 - 0.71) at a cutpoint= 0.395. The STOP-BAG model, which used dichotomous versions of the variables, had a sensitivity of 0.91 (95% CI 0.85-0.96) and specificity of 0.48 (95% CI 0.37 - 0.60) at cutpoint= 3.

Conclusion:
The STOP-BAG, consisting of 7 variables available in most EHRs, can be used to identify cerebrovascular patients at increased risk for OSA. A version that uses continuous variables (STOP-BAG2), can be used if automated score calculation can be done.
Abstract T P387: Stroke Health and Risk Education Project: main results
Authors: Brown Devin , Conley Kathleen , Sanchez Brisa , Resnicow Ken , Cowdery Joan , Sais Emma , Murphy Jillian , Skolarus Lesli , Lisabeth Lynda , Morgenstern Lewis
Published: March 2022

Objective:
The Stroke Health and Risk Education (SHARE) Project is a cluster-randomized, faith-based, culturally-sensitive, theory-based behavioral intervention trial to reduce key stroke risk factor behaviors.

Methods:
Ten Catholic churches in Corpus Christi, Texas were randomized to intervention or control group. Subjects were enrolled as friend or family partners who provided reciprocal support to each other. The intervention group received a 1-year multicomponent intervention that included self-help materials (physical activity guide with pedometer, healthy eating guide, blood pressure management photonovella, and motivational short film), 2 tailored newsletters, 5 motivational interviewing counseling calls, and a peer partnership support workshop. Multilevel modeling, accounting for clustering within pairs and parishes, was used to test treatment differences in the average of two measures of change since baseline (ascertained at 6 and 12 months), using standardized questionnaires, in dietary sodium, dietary fruit and vegetable intake, and physical activity of moderate or greater intensity. The primary endpoint was met if any one of the three outcomes was significant based on a pre-specified p-value threshold of 0.05/3.

Results:
Of 801 subjects who consented, 760 completed baseline data assessments. The median age was 52; 84% were Hispanic, the remainder were non-Hispanic whites; 64% were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 (95% CI: 0.08, 0.42) cups per day, p = 0.002), a greater decrease in sodium intake (-123.17 (-194.76, -51.59) mg/day, p=0.04), but no difference in change in moderate or greater intensity physical activity (-27.47 (-526.32, 471.38) MET-minutes per week, p=0.56).

Conclusion:
This cluster-randomized trial was effective in increasing fruit and vegetable intake among Hispanic and non-Hispanic white Catholic parishioners, reaching its primary endpoint. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts.
Abstract T P40: FLAIR Vascular Hyperintensity is a Marker of Collateral Flow Grade and Severity of Leukoaraiosis in Patients with Acute Ischemic Stroke
Authors: Karadeli Hasan H , Giurgiutiu Dan-Victor , Cloonan Lisa , Fitzpatrick Kaitlin , Kanakis Allison , Rost Natalia S
Published: March 2022

Introduction:
FLAIR Vascular Hyperintensity (FVH) is a novel radiographic marker detected on FLAIR MRI sequence in patients with acute ischemic stroke (AIS), which is linked to abnormal blood flow and potentially salvageable brain tissue. Poor leptomeningeal collateral status in AIS patients with proximal artery occlusion (PAO) is associated with larger final infarct size and worse clinical outcomes, which are also known to be affected by severity of white matter hyperintensity (WMH). We sought to evaluate the utility of FVH as a marker of acute collateral vessel status and its association with WMH burden in AIS patients.

Methods:
Consecutive AIS patients admitted to our center with PAO on baseline CT angiography (CTA) were retrospectively selected from a prospectively derived database. FVH was assessed on admission FLAIR MRI obtained immediately after IV tPA administration. FVH was graded by its location (0-none, 1-proximal, 2-distal, and 3-both); degree (0-none, 1-subtle, 2-prominent, and 3-both); and its score (0-none, 1-less than four hyperintense vessels, and 2-four or more hyperintense vessels). Collateral flow grade was ranked on admission CTA using previously published method. WMH volume (WMHV) was assessed using a validated, semi-automated volumetric MRI-based protocol. The relationship between FVH, collateral flow grade, and WMHV were analyzed.

Results:
A total of 39 patients were included in this study (mean age 70.5±12.7 years; 56% women, mean NIHSS score 17.2±4.4 points). Median WMHV was 6.0 cm3 (interquartile range [IQR] 3.4-9.6 cm3). Median DWI volume was 17.7 cm3 (IQR 9.9-26.0 cm3). FVH score and collateral flow grade were significantly correlated (Spearman’s rank correlation ρ=0.41, p=0.009). In a univariate regression model, FVH degree was inversely associated with WMHV volume (β=-0.33, p=0.04).

Conclusions:
FVH score detected on acute FLAIR MRI can be used as a marker of collateral flow grade in patients with AIS. Degree of FVH is inversely associated with WMHV, possibly signifying the diffuse disease of cerebral vasculature in patients with severe leukoraiosis.
Abstract T P400: Subarachnoid Hemorrhage-Induced Reactive Astrogliosis Is Correlated With Inversion of Neurovascular Coupling
Authors: Tranmer Andrew , Benoit Zach , Wellman George , Koide Masayo
Published: March 2022

Poor patient outcome following aneurysmal subarachnoid hemorrhage (SAH) has been linked to delayed cerebral ischemia (DCI), presenting several days following aneurysm rupture. Enhanced constriction of the brain vasculature, including intracerebral (parenchymal) arterioles contribute to SAH-induced DCI. Activity-dependent blood flow through parenchymal arterioles is controlled by local neuronal and astrocytic activity, a process known as neurovascular coupling. In response to numerous types of brain insults (e.g. tumors, trauma, and strokes), astrocytes undergo a transformation to a reactive phenotype, reactive astrogliosis, characterized by hypertrophy and hyperplasia. Here, we examined the hypothesis that SAH-induced reactive gliosis of perivascular astrocytes contribute to enhanced parenchymal arteriolar constriction. Astrocyte and vascular changes were assessed in a mouse endovascular perforation SAH model. Glial fibrillary acidic protein (GFAP), an astrocyte-specific intermediate filament that is upregulated during reactive astrogliosis, was assessed by immunohistochemistry in brain cortex of the middle cerebral artery territory. We observed increased GFAP staining at Day 2 and Day 4 following induction of SAH when compared to brain sections from control and sham-operated animals (all p values <.05). In separate animals, neurovascular coupling was examined using two-photon and infrared-differential interference contrast microscopy. In brain slices from control and sham-operated animals, neuronal activation caused the anticipated neurovascular response-an increase in astrocyte endfoot Ca2+ followed by parenchymal arteriole dilation. In marked contrast, brain slices from SAH animals exhibited an inverted neurovascular response (i.e. vasoconstriction rather than vasodilation) in ≈ 80% of brain slices from day 1 and day 2 SAH mice and ≈ 60% of slices from SAH day 4 mice. In conclusion, we demonstrate changes in astrocyte structure, the development of reactive astrogliosis, correlate to a polarity shift in neurovascular coupling after SAH. These data indicates that SAH-induced reactive astrogliosis may play an important role in DCI development.
Abstract T P409: Experimental Chronic Cerebral Hypoperfusion Results in Decreased Pericyte Coverage and Increased Blood Brain Barrier Permeability in the Corpus Callosum
Authors: Liu Qinghai , Radwanski Ryan , Babadjouni Robin , Baumbacher Peter , Russin Jonathan , Zhao Zhen , Mack William
Published: March 2022

Murine chronic cerebral hypoperfusion (CCH) results in white matter (WM) injury and behavioral deficits. Underlying mechanisms remain unclear. Pericytes influence blood-brain barrier (BBB) integrity and cerebral blood flow. Under hypoxic conditions, perictyes detach from perivascular locations increasing blood vessel permeability and secondary neuronal injury.

This study aims to characterize the time course of BBB dysfunction and pericyte coverage following murine experimental CCH. White matter injury and behavioral deficits have been reported consistently on post-operative day 30 in this model.

C57BL/6J mice underwent either CCH (n=12) or sham operation (n=9). BBB permeability in the corpus callosum (CC) was characterized on post-procedure days 1, 3, 7, and 30 using Evans blue (EB) extravasation and IgG staining. Pericyte coverage (CD 13/CD31 ratio) in the paramedian region of the corpus callosum was calculated on post-procedure days 1, 3, 7, and 30.

The CCH cohort demonstrated increased EB extravasation (integrate density) on postoperative days 1,3,7 and 30 when compared to the sham cohort (CCH: 583.58 ±98.28, 1529.32 ±448.87, 366.02 ±34.51, 5.85 ±1.80; SHAM: 44.51, 230.22, 24.03, 2.55 on postoperative days 1, 3, 7, and 30 respectively.) Further EB extravasation was significantly greater (p<0.05 ) at day 3 (peak level) than at days 7 and 30 in CCH mice. Positive IgG staining was seen at post-procedure days 3, 7, and 30 in the CCH group, but not in the sham operated mice. The CCH mice demonstrated a nadir in pericyte coverage on post-operative day 3 (30.88 ±10.27%). These values were significantly lower (p<0.05) than those on postoperative days 7 (89.36 ±5.11%), and 30 (74.97 ±2.39%). The post-operative day 3 pericyte coverage ratios were also significantly decreased compared to those in the sham mice (72.09 ±3.89%; p<0.01).

Decreased pericyte coverage and increased BBB permeability are most pronounced on postoperative day 3 following murine experimental CCH. This precedes any notable WM injury or behavioral deficits (post-op. day 30). Morphologic pericyte changes are concordant with BBB breakdown. Neurotoxic macromolecule extravasation may contribute to the pathogenesis of WM lesions and resultant behavioral deficits in this model system.
Abstract T P416: Bilateral Common Carotid Artery Stenosis in Normotensive Rats Impairs Short-Term Memory and Dilation in Penetrating Arterioles
Authors: Matin Nusrat , Jackson William F , Dorrance Anne
Published: March 2022

Chronic cerebral hypoperfusion (CCH) is a risk factor for cognitive impairment. Reduced blood flow through the common carotid arteries induced by bilateral common carotid artery stenosis (BCAS) is a physiologically relevant model of CCH. We hypothesized that BCAS in Wistar Kyoto (WKY) rats would impair cognitive function, we further proposed that in an effort to compensate for the reduced blood flow BCAS would lead to increased dilation and outward remodeling in the penetrating arterioles (PAs). Data are shown as mean±SEM, SHAM vs BCAS. BCAS reduced pial artery perfusion in 20-week-old male WKY rats (469±8 vs 299±21 perfusion units p<0.05). Short-term memory, evaluated by novel object recognition testing, was impaired (novel exploration quotient: 0.62±0.09 vs 0.46±0.14, p<0.05). PA reactivity and structure were assessed by pressure myography. There was no difference in myogenic tone between the groups [SHAM (n=4) and BCAS (n=7), % average tone: 34.5±9.8]. Contrary to our hypothesis, BCAS impaired endothelial function of PAs from 28-29 weeks old WKY rats, as evidenced by reduced dilation to endothelium dependent dilator carbachol (% change in diameter from baseline at 10-5M: 7.0±4.1 vs -1.8±5.6, Student’s t-test p<0.05). Inhibition of nitric oxide and prostacyclin production did not change the response to carbachol or the myogenic tone in either group. This suggests that endothelium derived hyperpolarizing factor (EDHF) plays a role in PA dilation in the SHAM rats; the role of EDHF in the PAs from the BCAS rats remains to be investigated but the lack of dilation to carbachol under any conditions suggests a general impairment in endothelial function. There was no difference in the PA passive structure between the groups. Work from our lab suggests that CCH leads to outward remodeling of the posterior communicating artery (PCA). Lumen diameter of the PCAs is important in regulating the severity of CCH. BCAS increased lumen diameter, wall-to-lumen ratio and distensibility of the PCAs (two-way ANOVA, p<0.05). These data suggest that BCAS impairs short-term memory, and may contribute to impaired endothelium dependent dilation of the PAs. BCAS in normotensive WKY rats also leads to outward remodeling in the PCAs but it did not alter PA passive structure.
Abstract T P417: Remote Ischemic Post Conditioning (RIPostC) Is Effective In A Mouse Model Of Vascular Cognitive Impairment
Authors: Khan Mohammad B , Vaibhav Kumar , Hoda Md N , Hess David C
Published: March 2022

Background and Purpose:
The mouse bilateral common carotid artery stenosis (BCAS) model is regarded as the best animal model for vascular cognitive impairment (VCI). RIPostC is a simple and safe therapy that others and we found protective in ischemic stroke. Other than risk factor control, there are no established treatments for VCI. However observational studies suggest exercise may be effective in patients with leukoaraiosis and cognitive impairment, the major form of VCI. Since RIPostC and exercise share some common mechanisms of action, we hypothesized that RIPostC would be effective in the mouse BCAS model and in VCI.

Methods:
Adult C57BL/6J male mice of (10-weeks) were subjected to either Sham for BCAS or BCAS surgery using micro coils twined around common carotid arteries. We randomized BCAS mice to daily RIPostC or sham procedure for RIPostC beginning 7 days post-BCAS for 2 weeks until day 21. Cerebral blood flow (CBF) was measured by laser speckle contrast imager. All mice underwent blinded testing for cognitive functions using novel object recognition (NOR). Histopathological examination and beta amyloid contents were investigated in the brain at day 30 post-BCAS. Statistical significance was determined at p <0.05.

Results:
At 1 hour, CBF was decreased significantly in all animals subjected to BCAS. RIPostC improved CBF in comparison to sham-operated group for RIPostC at day 14 and 28 post-VCI (p<0.05). BCAS impaired the discrimination index of mice in the NOR test but this was improved in the BCAS group treated with RIPostC (p<.05). Histopathological studies revealed that BCAS caused frequent vacuolization, cell death, microglial activation, loss in white matter (WM) and increased accumulation of beta amyloid. This was all attenuated significantly with RIPostC.

Conclusions:
RIPostC improves CBF, cognition and reduces cell death, WM damage and beta amyloid accumulation in the mouse BCAS model. Chronic RIPostC-therapy might be an effective treatment for VCI and in patients with leukoaraiosis and cognitive impairment

Key words:
RIPostC, VCI, white matter, beta-amyloid
Abstract T P50: Vanishing of Hyperintense Vessels on FLAIR Predicts Good Outcome in Tissue Plasminogen Activator Patients
Authors: Sakuta Kenichi , Saji Naoki , Aoki Junya , Shibazaki Kensaku , Iguchi Yasuyuki , Kimura Kazumi
Published: March 2022

Background and Purpose:
Hyperintense vessels (HV) on FLAIR detected in patients with acute ischemic stroke indicate cerebral hypoperfusion. Thus, vanishing of HV should indicate reperfusion. We investigated serial changes of HV in patients who received tissue plasminogen activator (t-PA) therapy, comparing changes with clinical outcomes.

Methods:
We studied t-PA patients presenting with HV on FLAIR in the middle cerebral artery territory. Patients underwent brain MRI before and 1 hour after t-PA infusion. HV scores (range, 1–7) were evaluated according to ASPECTS territories. Patients were divided into two groups based on whether there was a decrease in HV scores (DHV). Multivariate logistic regression analysis was conducted to identify variables independently associated with good outcomes.

Results:
A total of 118 patients were consecutively enrolled (73 men; mean age, 76±9.7 years; median initial HV score, 5), and 52 (44%) were classified as DHV. Patients in the DHV group had statistically significantly lower NIHSS time course (P<0.001) and smaller infarct volume time course (P<0.001) compared with those not in the DHV group. Multivariate analysis, adjusting for age, sex, glucose, atrial fibrillation, ICA occlusion, baseline NIHSS, time from stroke onset to treatment, and infarct volume on admission, showed that DHV was independently associated with good outcomes (OR 3.59, 95% CI, 1.58–9.97, P<0.01). The sensitivity and specificity of DHV for good outcome were 70% and 68%, respectively.

Conclusion:
Vanishing of HV on FLAIR predicts good outcome in patients receiving t-PA therapy.