bluuebunny/crossref_metadata_2025 huggingface dataset:
Abstract P359: Secondary Thalamic Atrophy Related to Brain Infarction is Associated With Post-Stroke Cognitive Impairment
Authors: Geng Jieli , Honjo Kie , Gao Fuqiang , Ramirez Joel , Holmes Melissa , Adamo Sabrina , Ozzoude Miracle , Scott Christopher J , Goubran Maged , Nyenhuis David L , Black Sandra E
Published: March 2021

Background:
The thalamus is globally connected to many brain regions. Previous work highlights thalamic contributions to multiple cognitive functions, but few studies have measured thalamic volume changes or explored correlates of such changes with post-stroke cognition. Hence this study investigates possible associations of thalamic volumes with post-stroke cognitive functions.

Methods:
Participants with brain infarcts (6-42 months) underwent volumetric brain MRI and cognitive testing, including the Montreal Cognitive Assessment (MoCA). Focal Brain infarcts and thalami were traced manually. If the patient had bilateral infarcts, the side of the primary infarct volume defined the hemisphere involved. Brain parcellation and volumetrics used our comprehensive semi-automatic brain region and vascular lesion extraction pipeline (Ramirez, Neuroimage, 2011). MRI in 24 age and gender-matched healthy people provided normal comparative thalamic volumes. Thalamic atrophy was defined by percent thalamic volume loss in the stroke hemisphere compared to the other side. Spearman correlation assessed relationships between thalamic and infarct volumes and MoCA scores. Logistic regression analysis assessed whether thalamic atrophy correlated with MoCA score.

Results:
Thalami volumes ipsilateral to the infarct in stroke patients (n=55) were smaller than left (4.4 ± 1.4 vs. 5.4 ± 0.8 cc, p = 0.012) and right (4.4 ± 1.4 vs. 5.3 ± 0.7 cc, p = 0.024) thalamic volumes in the controls. Thalamic volumes were inversely correlated with ipsilateral infarct volumes (r = -0.384, p = 0.004). After controlling for head-size and brain atrophy, infarct volume independently correlated with ipsilateral thalamic volume s (β= -0.068, P=0.026), and only frontal infarcts (β = 2.300, p = 0.021) independently contributed to > 15% ipsilateral thalamic atrophy. Left thalamic atrophy of > 10% correlated significantly with poorer MoCA performance (β = 3.139, p = 0.023), after controlling for demographics and infarct volumes.

Conclusions:
Our results suggest that remote effects of infarction on ipsilateral thalamic volume, presumably related to disrupted thalamic-cortical interconnectivity, is associated with a commonly used metric of post-stroke cognitive impairment.
Abstract P362: A Volumetric Comparison of Computed Tomography Perfusion Rapid Core Volume in Different Time Frames With Diffusion-Weighted Imaging Infarct Volume in the Post-Thrombectomy Patients After Large Vessel Occlusion
Authors: Bhagat Riwaj , Madireddy Krishna , Naik Shivani , Kutty Gopika , Liu Wei
Published: March 2021

Introduction:
The Computed Tomography Perfusion (CTP) RAPID software is widely used for the patient selection for mechanical thrombectomy (MT) after anterior circulation large vessel occlusion (LVO). There is a notion that it overestimates the core volume (CV) in an earlier time frame from symptom onset. We compared the accuracy of CTP RAPID estimated CV in different time frames with diffusion weighted imaging (DWI) infarct volume (IV).

Method:
A retrospective data review of patients who underwent MT for anterior circulation LVO with TICI 2b/3 reperfusion from 2017 to 2019 was done. Patients with baseline CTP and follow up 36-hour MRI was included. Patients with parenchymal hematoma, graded as per ECASS II classification were excluded. CTP time was dichotomized as 0-3 hours (hrs) and >3 hrs from symptom onset. DWI IV was calculated by ABC/2 formula. The volumetric difference (VD), defined as DWI IV minus CTP CV, core volume overestimation (CVO), defined as CTP CV minus DWI IV and CT ASPECTS was calculated. Large CV was defined as >50 ml CV. Standard descriptive statistics and independent sample T-test were used as statistical tools.

Result:
Total MT cases (n) were 61. Mean age (y.o) was 66 (SD 13.9) (male 57.4%). In < 3 hrs from symptom onset (n 27), mean CTP CV was 38.8 ml (SD 39.8), DWI IV was 39.6 ml (SD 51.4), VD was 0.9 ml (SD 55.2) (p 0.945) and CVO (n 11) was 39.6 ml (SD 35.7) (p 0.008). Mean large CV (n 8) was 78.3 ml (SD 25.4) with median CT ASPECTS of 8 (IQR 6.5-9) and median mRS at discharge 2 (IQR 0.8- 3.3). In >3 hrs from symptom onset (n 34), mean CTP CV was 28.81 ml (SD 47.4), DWI IV was 75.3 ml (SD 69.5), VD was 46.5 ml (SD 61.8) (p 0.002) and CVO (n 5) was 25.2 ml (SD 41.27) (p 0.60). Mean large CV (n 5) was 116.8 ml (SD 75.3) with median CT ASPECTS of 6 (IQR 5-7) and median mRS at discharge 5 (IQR 4- 6).

Conclusion:
Overestimated core volume on CTP was seen in more than one third cases within 3 hours from symptom onset. Large CV estimated within this time frame had higher CT ASPECTS and good functional outcome at discharge.
Abstract P371: Automated Approach of Final Infarct Volume Measurement on Acute Ischemic Stroke
Authors: Pisani Leonardo , Carone Davide , Mohammaden Mahmoud , Harston George , Al-bayati Alhamza R , Haussen Diogo C , Frankel Michael R , Nogueira Raul G
Published: March 2021

Introduction:
Final infarct volume (FIV) is a commonly used imaging endpoint in stroke trials. The aim of this study was to investigate the potential of an automated masking pipeline (Brain Intensity AbNormality Classification Algorithm - BIANCA) on detecting ischemic stroke lesions of follow-up imaging on patients with acute ischemic stroke.

Methods:
Patients were retrospectively selected from a prospectively acquired mechanical thrombectomy (MT) database from January to July 2019, and were included if they had a follow-up magnetic resonance imaging DWI within 72h from procedure available. Masks were generated on B1000 imaging by clinical research stroke personnel and then compared with volumes delineated by a fully automated supervised method for lesion detection, based on a k-nearest neighbor (k-NN) algorithm.

Results:
Seventy patients were included. Human FIV measurements mean was comparable with BIANCA [67.7±73.2 vs 71.8±67 (p<0.05)]. Dice similarity index showed to be 0.710 whilst the ICC was 0.960 (p<0.05).

Conclusion:
The automated masking pipeline measurement showed to behighlysimilar to a standardized protocol of FIV estimation at a busy neuroendovascular center and could be used in trials with large numbers of patients.
Abstract P376: ASPECTS Decay and Functional Outcomes in Inter-Facilities Transferred Large Vessel Occlusion Acute Ischemic Stroke
Authors: Abdulrazzak Mohammad Ammar , Sarraj Amrou , Greco Jonathan , Azher Aidan I , Qadri Syed , Shaker Faris , Pujara Deep K
Published: March 2021

Background and objective:
Endovascular Thrombectomy (EVT) treatment for patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) was shown to improve functional outcomes. However, many eligible patients have no direct access to EVT capable centers, necessitating emergent inter-facilities transfers. Prolonged transfer time and reperfusion delay result in stroke progression and poor long-term outcomes. We evaluated the correlation between stroke evolution on non-enhanced Computed Tomography (CT) determined by Alberta Stroke Program Early CT Score (ASPECTS) decay and functional outcomes in transferred LVO patients.

Method:
Retrospective analysis of prospectively collected comprehensive stroke center data of patients with anterior circulation LVO (ICA, MCA M1 & M2) transferred for EVT. Stroke evolution was assessed based on CT ASPECTS decay defined as: [Outside hospital ASPECTS - Arrival pre-treatment ASPECTS]. A significant ASPECTS decay was defined as at least 2 points decrement in ASPECTS from initial imaging. Primary outcome was functional independence at 90-days, mRS 0-2. The correlation between functional independence and ASPECTS decay was assessed using logistic regression.

Results:
Of 108 patients transferred for EVT both initial outside and follow up CTs were available for 78 patients. Median IQR NIHSS was 16 (11, 20), age was 65.5 (54, 77), 33 (42%) of patients were women. Time from LKW to groin puncture was 9.91 (5.77, 13.35) hours and time from initial CT to repeat images was 3.6 (2.5, 4.8) hours. Median IQR ASPECTS decay was 1 (1, 2). Median IQR ASPECTS decay/hour 0.3 (0.0, 0.6). Significant ASPECTS decay was observed in 32 (41%) patients, and was more likely to occur with images repeated more than 3 hours from initial imaging (38% vs 10%, P<0.001). Significant ASPECTS decay correlated with decreased likelihood of achieving independence at 90-days (AOR: 0.21, 95% CI 0.04-0.99, P-value=0.048).

Conclusion:
ASPECTS decay was more likely to occur in prolonged transfers and correlated with lower likelihood of functional independence following EVT. Expedited transfers and faster reperfusion are vital to optimize thrombectomy outcomes in transfer patients.
Abstract P38: Pooled Analysis of Long and Short Term Outcomes After Subarachnoid Hemorrhage - International Stroke Outcomes Study (INSTRUCT)
Authors: Rehman Sabah , Phan Hoang T , Reeves Mathew J , Thrift Amanda G , Cadilhac Dominique A , Sturm Jonathan , Breslin Monique , Callisaya Michele , Vemmos Kostas N , Parmar Priya G , Krishnamurthi Rita V , Barker-Collo Suzanne , Feigin Valery L , Chausson Nicolas , Olindo Stephane , Cabral Norberto , Carolei Antonio , Marini Carmine , Sacco Simona , Correia Manuel , Appelros Peter , Korv Janika , Vibo Riina , Minelli Cesar , Sposato Luciano , Pandian Jeyaraj D , Kaur Paramdeep , Azarpazhooh M. Reza , Morovatdar Negar , Gall Seana L
Published: March 2021

Background:
Outcomes after subarachnoid hemorrhage (SAH) have been rarely examined in large cohorts.

Methods:
This is an extension of the International Stroke Outcomes Study (INSTRUCT) pooling 13 ‘ideal’ stroke incidence studies (n=657 with SAH from 1993-2017, median age 56 years; 46% men). The primary outcomes were mortality and functional outcome (mRS score 3-5). Harmonized study factors included age, sex, behaviors (current smoking, alcohol intake), comorbidities (history of hypertension, ischemic heart disease, atrial fibrillation), stroke severity (e.g. NIHSS score) and year of stroke. In the pooled dataset, we estimated predictors of mortality using Poisson regression, to estimate incidence rate ratio (IRR) at 1 month (11 studies), 1 year (12 studies) and 5 years (7 studies). Generalized equation estimates in the log-binomial family were used to calculate risk ratios (RRs) for predictors of poor functional outcome at 1 month (5 studies) and 1 year (8 studies).

Results:
Mortality was 33% at 1 month, 43% at 1 year, and 47% at 5 years (Fig 1). Poor functional outcome was 25% at 1 month and 15% at 1 year (Fig 1). In multivariable analysis, age and stroke severity were associated with mortality at all time points, together with current smoking at 1 and 5 years, and history of hypertension at 5 years (Fig 2). Poor functional outcome was predicted by age (RR 1.03; 95% CI 1.01-1.04) at 1 month and by age (RR 1.04; 95% CI 1.00-1.08) and stroke severity (RR 1.94; 95% CI 1.02-2.87) at 1 year.

Conclusion:
Risk factors that predict SAH incidence including hypertension and smoking make outcomes worse. Better management of older patients and those with severe strokes could improve outcomes after SAH.
Abstract P380: Eloquence Mapping in Acute Ischaemic Stroke
Authors: Brinjikji Waleed , Rabinstein Alejandro A , Harston George , Joly Olivier , Abbasi Mehdi , Kallmes David
Published: March 2021

Introduction:
Patient selection for acute stroke revascularisation therapies is commonly based on clinical-imaging mismatch paradigms. Anatomical scores or total volumes of brain affected are assumed to correlate with clinical deficit without reference to the functional eloquence of the regions involved. In this study we used the relationship between presenting hypoperfusion abnormality and the corresponding NIHSS to generate functionally weighted atlases from patients with acute ischaemic stroke.

Methods:
Patients with acute large vessel occlusion (LVO) of the anterior circulation and with CTP at the time of presentation were included in this study. CTP was analysed with e-CTP (Brainomix Ltd., Oxford, UK) and hypoperfusion maps defined (Tmax >6s). Voxelwise lesion to symptom mapping was used to generate probability maps associating regions of hypoperfusion with clinical deficit at presentation.

Results:
58 patients with itemised NIHSS and CTP were included. Discrete patterns of deficit were associated with each NIHSS domain. Total NIHSS correlated most strongly with left MCA involvement, consistent with the weighting towards language in this clinical scale. Regions associated with upper and lower limb deficits identified the respective motor cortex regions and descending motor tracts. Example mapping is presented in the Figure (A: total NIHSS, B: left arm paresis, C: left leg paresis). Data from a larger cohort will be presented at the meeting.

Conclusions:
Functional mapping using associations between presenting NIHSS and hypoperfusion lesion can be used to create eloquence-weighted atlases. Such atlases from stroke patients may be helpful to develop tools to predict clinical deficit associated with a presenting ischemic core lesion defined on non-contrast CT or CTP. This approach could refine clinical-imaging mismatch concepts, expanding endovascular treatment to a wider group of patients who would not currently be treated.
Abstract P382: Assessing the Impact of Damage to Brainstem Tracts on Motor Ability in Ischemic Stroke Patients
Authors: Olafson Emily , Jamison Keith , Liu Hesheng , Wang Danhong , Bruss Joel , Boes Aaron , Kuceyeski Amy
Published: March 2021

The extent of disruption to the corticospinal tract has been associated with motor impairment and worse recovery, but the role of other motor and sensorimotor tracts in impairment following brainstem stroke is poorly understood. Additionally, the impact of brainstem strokes on connectivity to distal cortical regions innervated by these tracts has not been well established. In 23 first-episode unilateral brainstem ischemic stroke patients, the extent of disruption to brainstem pathways was determined using the Dice score between binarized lesion masks obtained from T1 images and each of 23 brainstem tracts defined using a recently published high-resolution atlas of the brainstem based on connectome imaging data. Motor impairment was determined using the Fugl-Meyer assessment. White matter disruption due to the stroke was estimated using the Network Modification Tool 2.0 (NeMo) tool, which calculates the proportion of fiber tracts disrupted by the lesion in each voxel. Principal components analysis (PCA) was used to determine disruption patterns across patients. PCA of Dice scores identified one component which explained 65% of the variance, which corresponded to overlap with the corticospinal (CST), frontopontine (FPT), and parieto-occipito-temporo-pontine (POTPT) tracts, as well as the middle cerebellar peduncle. Component scores significantly correlated with Fugl-Meyer scores (corr. = -0.82, p < 0.01). PCA of cortical disconnectivity revealed one principal component which explained 75% of the variance, which correlated most highly with cortical regions connected to the CST, FPT, and the POTPT and whose scores also significantly correlated with Fugl-Meyer scores (corr. = -0.65, p < 0.01).
Abstract P383: AI-Guided Detection and Volumetric Analysis of Embolic and Watershed Infarcts on Diffusion-Weighted MRI Enables Measurement of the Absolute and Relative Ischemic Infarct Burden
Authors: Kasischke Karl A , Burgin W S
Published: March 2021

Acute ischemic strokes frequently present with multiple restricted diffusion lesions scattered throughout the brain parenchyma, particularly embolic and watershed infarcts. The morphological variety and complexity of such infarcts are high in terms of their potential number, shape, volume, and spatial distribution. In current clinical practice, there is a limited description of the burden and variability of such infarcts. Here, we demonstrate an artificial-intelligence guided approach using high-performance computing, for the fast (minutes) and precise (sub-milliliter) detection and quantification of each infarcted brain volume regardless of size and morphology. Our methodology is based on processing and analyzing the original DICOM data by filtering, segmentation, and morphological neighborhood operations to identify and triage 3D-connected volumes of interest that represent ischemic stroke. Figure Panel A shows the analysis of a watershed stroke with the identification of 5 ischemic subvolumes with an overall infarct volume of 23.6 ml and a relative infarct volume of 2.0 % of the total brain volume of 1152 ml. In contrast, Figure Panel B shows the analysis of an embolic stroke with the identification of 20 ischemic subvolumes with an overall infarct volume of 51.6 ml and a relative infarct volume of 4.4 % of the total brain volume of 1178 ml. What is novel here is that our approach allows for the immediate measurement of the absolute (in ml) and relative (in terms of % of total brain volume) infarct burdens of complex strokes on initial MRI imaging. Volumetric analysis of stroke may represent a critical future biomarker. We suggest that such an approach might be easily implemented into clinical and research settings to guide clinical diagnoses, therapeutic decisions, and outcome prediction.
Abstract P385: Stroke-Related Hospital Admissions During Covid-19 Pandemic in the Latin American Stroke Registry (LASE)
Authors: Pujol-Lereis Virginia , Flores Alan , Arauz Antonio , Abanto-Argomedo Carlos , Amaya Pablo , Bayona Hernán , Bonardo Pablo , Diaz-Escobar Luis , Gomez-Schneider Maia , Góngora-Rivera Fernando , Lavados Pablo M , León Carolina , Luraschi Adriana , Márquez-Romero Juan Manuel , Martins Sheila C , Navia Victor Hugo , Ruiz-Franco Angelica , Vences Miguel Angel , Zurrú María Cristina , Barboza Miguel A , Ameriso Sebastián F ,   LASE/COVID-19 Collaborators
Published: March 2021

Background:
COVID-19 pandemic has forced important changes in health care worldwide. Stroke care networks have been affected, especially acute admissions and ancillary tests availability. We assessed the impact of the pandemic and the lockdowns imposed in stroke admissions in Latin America.

Methods:
A multinational study (7 countries, 18 centers) of patients admitted since the pandemic outbreak (January - June 2020). These cases were compared with the same period in 2019. We also assessed patterns during the strictest lockdown period (March-June 2020). Number of cases, stroke etiology and severity, acute care and functional outcomes were compared per periods, months, centers and countries.

Results:
There were 1863 stroke cases in 2019 and 1781 cases in 2020 (p=0.02). We found a significant increase in strokes of undetermined etiology due to incomplete studies in 2020 [16.8% vs 27.6%, p<0.001]). Most countries reported decreases in all-type stroke admissions, except México and Brasil (16% and 36% increases in admissions, respectively). There were no significant differences among months. All-type mortality increased (6.2% vs. 12.6%, p<0.001), and poor functional outcome (mRs 3-6) increased from 32.2% to 38.8% (p=0.007) in 2020. During the period of strict lockdown (March-June 2020), ischemic stroke admissions during the first 24 hours of onset (68.3% vs. 64.4%, p=0.1) and in-hospital stroke code activation (35.1% vs. 27.6%, p=0.005) diminished compared to 2019 period. No differences in total reperfusion treatment rates were observed, with similar door-to-needle and door-to-groin times in both periods.

Conclusions:
All-type stroke admissions diminished only slightly during the first months of the COVID-19 pandemic. However, in this region, we found substantial deficiencies in stroke work-up, poor short-term outcome and increased mortality.
Abstract P386: Reducing Laboratory Testing in Hospitalized Stroke Patients Using Machine Learning
Authors: Kim Yejin , Jiang Xiaoqian , Samuel Sophie , Savitz Sean I
Published: March 2021

Introduction:
Despite previous studies indicating a high rate of overuse, in-hospital laboratory blood testing remains common. Repeated laboratory tests often return normal and lead to increased cost and even anemia. We hypothesize this situation is highly significant among hospitalized stroke patients. We used machine learning to reduce the freqeuency of repeated lab testing for stroke patients as a proof of concept.

Method:
We used stroke patients in the MIMIC III database to develop a novel deep learning algorithm that takes into account the characteristics of all study patients to predict whether repeating a lab test is necessary and aid in decisions of obtaining subsequent laboratory tests. Our model jointly considers temporal and spatial correlations of lab tests to make predictions of future test abnormality. We included 12 tests for electrolytes, renal function, and Complete Blood Count. We defined an error as recommending the reduction of a laboratory study when the testing would have yielded a critical abnormal result which should have been tested (Table 1).

Results:
We analyzed 3,178 stroke patients (293,433 lab results). Our training cohort was used to develop the algorithm and the testing data were used to generate results. In the testing cohort, we could maintain a 99.8% accuracy with a 52% reduction of all lab tests, which corresponded to a total reduction of 29,803 lab tests (74 false negatives). Different labs can be reduced at different rates. K and Cl were relatively easy to predict a critical abnormality on repeat testing while Ca and Mg displayed boundaries that were harder to predict abnormalties.

Conclusions:
Reducing lab testing by 52% from this stroke patient cohort maintained accuracy of testing at 99.8%. Our data suggest that multiple or daily laboratory orders are unlikely to change patient management given the high accuracy proposed by the machine learning approach.

Table 1:
normal range and critical abnormality for the 12 tests of interest
Abstract P397: Outcomes in Acute Ischemic Stroke Patients Presenting With Impaired Level of Consciousness
Authors: Alkhachroum Ayham , Bustillo Antonio , Asdaghi Negar , Marulanda-londono Erika T , Gutierrez Carolina M , Samano Daniel , Sobczak Evie , Kottapally Mohan , Merenda Amedeo , Koch Sebastian , Romano Jose G , O’Phelan Kristine , Claassen Jan , Sacco Ralph L , Rundek Tatjana
Published: March 2021

Background:
Impaired level of consciousness (LOC) on presentation after acute ischemic stroke (AIS) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and their trends after AISby the LOC on stroke presentation.

Methods:
We studied 238,989 cases with AIS in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, stroke severity, location, hospital size and teaching status.

Results:
At stroke presentation, 32,861 (14%) cases had impaired LOC (mean age 77, 54% women, 60 white%, 19% Black, 16% Hispanic). Compared to cases with preserved LOC, impaired cases were older (77 vs. 72 years old), more women (54% vs. 48%), had more comorbidities, greater stroke severity on NIHSS ≥ 5 (49% vs. 27%), higher WLST rates (3% vs. 0.6%), and greater in-hospital mortality rates (9% vs. 3%). In our adjusted model however, no significant association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.7, 95%CI 0.6-0.8, p<0.0001) and more likely to ambulate independently (OR 0.7, 95%CI 0.6-0.9, p=0.001). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all irrespective of LOC status.

Conclusion:
In this large multicenter registry, AIS cases presenting with impaired LOC had more severe strokes at presentation. Although LOC was not associated with significantly worse in-hospital morality, it was associated with higher rates of WLST and more disability among survivors. Future efforts should focus on biomarkers of LOC that discriminates the potential for early recovery and reduced disability in acute stroke patients with impaired LOC.
Abstract P40: Declining Morbidity From Subarachnoid Hemorrhage in the Last 4 Decades: A Pooled Analysis of 13,343 Patients
Authors: Neifert Sean , Oermann Eric , Mocco J D , Todd Michael M , Torner James , Molyneux Andrew , Mayer Stephan A , Leroux Peter , Vergouwen Mervyn D , Rinkel Gabriel J , Wong George K , Kirkpatrick Peter , Quinn Audrey , HÄNGGI Daniel , Etminan Nima , van den Bergh Walter , Jaja Blessing , Cusimano Michael , Schweizer Tom , Suarez Jose I , Fukuda Hitoshi , Yamagata Sen , Lo Benjamin , Manoel Airton Leonardo D , Boogaarts Hieronymus , MacDonald R Loch
Published: March 2021

Introduction:
Subarachnoid hemorrhage (SAH) mortality is decreasing, but data on functional outcomes over time is lacking.

Methods:
We created trends of good (Glasgow Outcomes Scale [GOS] of 4 or 5) and optimal (GOS of 5) functional outcomes and mortality (GOS of 1) using linear regression in 15 SAH trials and registries from 1982 to 2014. Models adjusted for age, sex, history of hypertension, World Federation of Neurological Surgeons grade, Fisher grade, aneurysm size, location, and repair modality, and whether data was from a clinical trial or registry. Analyses were repeated separately for the clinical trials and registries. Missing data were handled with multiple imputation.

Results:
Overall, 13,343 SAH patients were included. 9,524 (71%) patients had good functional outcome, while 1,608 (12%) died. There was a 0.6% adjusted improvement (95% confidence interval [CI]: 0.5% to 0.7%; p<0.001) per year in good functional outcome and a 0.1% adjusted reduction (95% CI: -0.2% to -0.08%; p<0.001) per year in mortality. For patients enrolled in clinical trials, there was no change good functional outcomes (0%; 95% CI: -0.2% to 0.1%; p=0.923) or mortality (0.0% change per year; 95% CI: -0.09% to 0.1%; p=0.676). Clinical registry patients experienced a 1.2% improvement (95% CI: 1.0% to 1.4%; p<0.001) in good functional outcome and a 0.3% reduction (95% CI: -0.4% to -0.1%; p<0.001) in mortality.

Conclusions:
SAH morbidity and mortality decreased from the 1980s to 2010s. This data can be helpful for researchers planning trials, clinicians discussing expected outcomes with patients and family members, and healthcare administrators planning resource utilization.
Abstract P408: A Meta-Genetic Risk Score Identifies Individuals at High Risk for Intracerebral Hemorrhage
Authors: Myserlis Evangelos Pavlos , Chung Jaeyoon , Parodi Livia , Abramson Jessica R , Rosand Jonathan , Anderson Christopher D
Published: March 2021

Introduction:
Genome-wide association studies (GWAS) have identified genetic associations for many common diseases and traits. However, incorporating genetic information into disease risk prediction has been challenging because any single collection of variants explains a small proportion of risk. We explored whether combining genetic information from related traits could improve our ability to predict ICH.

Methods:
We constructed an ICH meta-Genetic Risk Score (metaGRS) using 21 polygenic risk scores (PRSs) from GWASs of traits associated with ICH risk: systolic/diastolic blood pressure, pulse pressure, diabetes, hemoglobin A1c, total cholesterol, high/low-density lipoprotein, triglycerides, body mass index, waist-hip ratio, urine albumin-creatinine ratio, kidney disease, eGFR, white matter hyperintensities, small vessel stroke, insomnia, sleep duration, education attainment, alcohol use and smoking. Each PRS contained common, independent variants at p≤5x10
-4
with each trait. PRSs were calculated in 1,867 ICH cases/1,722 controls, using 1,019 cases/928 controls as a training dataset to derive logORs of the PRSs with ICH status, and a validation dataset of 848 cases/794 controls to construct the metaGRS as a weighted average.

Results:
Patients in higher metaGRS percentiles had higher odds of ICH
(Table)
, and a one standard deviation increase in metaGRS was associated with odds of ICH (OR 1.42; 95% CI: 1.28-1.57; p=1.6x10
-11
). Compared to patients in the middle decile of the metaGRS distribution, patients in the top 10% and 5% had increased odds of ICH (OR 1.87; 95% CI: 1.07-3.30; p=0.03, OR 2.72; 95% CI: 1.54-4.92; p=7.4x10
-4
respectively).

Conclusions:
A metaGRS identified individuals at high risk for ICH with an odds ratio comparable to traditional risk factors, such as hypertension (OR ~1.6). Further studies are needed to investigate the role of incorporating genetic information into clinical care.
Abstract P432: Large Scale, CTEvaluation Can Improve Screening for Multi-Center Stroke Trials
Authors: Jankowitz Brian T , Stinson Tammy , Begun Dina , Davies Jason
Published: March 2021

Introduction:
Artificial intelligence (AI) can automate the detection and triage of ICH. ENRICH is a RCT evaluating the efficacy of MIS for ICH. AI ENRICH is a prospective trial operating within and in parallel to the ENRICH trial that utilizes an AI application, Viz RECRUIT and ICH VOLUME to identify and segment ICH to quickly identify potentially eligible subjects.

Methods:
Non-contrast CT scans performed at 5 participating US hospitals were evaluated specifically for a parenchymal hemorrhage by Viz ICH VOLUME. Participating health care professionals downloaded a phone application that allowed one to be notified for any hemorrhage ≥ 5 mL. Time metrics included the onset of CT scan, phone alert, and user recognition of that alert.

Results:
Over a combined period of 220 days, 8714 CT scans were evaluated by the Viz ICH VOLUME application. Of these, 257 CT scans were determined to contain an ICH yielding a total of 45 patients that met ENRICH criteria for trial inclusion (30-80 mL). The median time from CT scan to cell phone notification was 2:52 minutes (IQR=0.002) . The median time from cell phone notification to the user viewing the CT scan was 3:00 minutes (IQR=55.5 minutes), which was altered by a few significant delays in recognizing the alert (e.g. coordination of alerts and call schedules). After segregating the 4 weeks after ENRICH restarted on 7/14/20 into 2 week blocks, recognition of an alert within 5 minutes increased from 9% to 61.5% at the first site and 36% to 61.5% at second site - demonstrating the ability of alerts to improve site engagement and active screening for new subjects.

Conclusions:
In conclusion, Viz ICH VOLUME can screen large numbers of CT scans and send alerts within minutes to medical professionals. Studies relying on radiographic selection criteria may benefit from automated screening, although participating health care providers need to make use of the technology in order to maximize benefit.
Abstract P435: Medical and Neurosurgical Interventions in Left Ventricular Assist Device-Associated Intracranial Hemorrhage
Authors: Ibeh Chinwe , TIRSCHWELL David L , Mahr Claudius , Creutzfeldt Claire J
Published: March 2021

Background:
Management of intracranial hemorrhage (ICH) in patients with left ventricular assist devices (LVADs) is complicated by the competing concerns of hematoma expansion and the risk of thrombotic events. Strategies include reversal or withholding of anticoagulation (AC) and neurosurgical (NSG) interventions. The consequences of these decisions can significantly impact both short- and long-term survival. Currently no guidelines on management exist. We reviewed medical and NSG practices and subsequent outcomes at a single academic center.

Methods:
We retrospectively identified all patients within our institutional LVAD database who developed ICH between 2012-2018. Demographic, clinical, and outcome data were analyzed.

Results:
Of 283 LVAD patients, 32 (11%) had 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%). IPH occurred sooner than other subtypes (median 138 [48 - 258]) days post-LVAD placement vs SDH (431 [22 - 915] days) and SAH (484 [272 - 990] days). Mean GCS was 12.9 (3.7). All patients were on AC with a mean INR of 3.3 (range 1.2 - 7.0). AC was reversed in 27 (79%) patients, most frequently with a combination of Vit K (56%), FFP (47%), or PCC (26%). AC was held in 31 patients a median of 4 (2.0 - 9.0) days; 1 thrombotic event occurred while off AC (spinal cord infarct). After AC resumption, 16 thrombotic events occurred a median of 15 (8.0-37.0) days post-ICH and led to death in most (79%) by 6 months. Five patients underwent NSG intervention: 1 hemicraniectomy, 3 EVDs, and 1 aneurysm coiling. Six patients (18%) went on to receive heart transplant. Overall, 30-day mortality was 26%. IPH had the highest 30-day mortality (38% vs SDH, 0% and SAH, 29%). At 6 months, overall mortality was 44%.

Conclusion:
ICH is a common post-LVAD complication with high short- and long-term mortality. Of the subtypes, IPH was the most common, most deadly and occurred the earliest following LVAD placement. At our institution, most patients underwent AC reversal but AC was also resumed rapidly. Delayed thrombotic complications nearly doubled 6-month mortality. The development of ICH did not preclude successful heart transplant. Further research in the care of LVAD patients with ICH may help improve these short- and long-term outcomes.
Abstract P436: Outcomes in Intracerebral Hemorrhage Patients Presenting With Impaired Level of Consciousness
Authors: Alkhachroum Ayham , Bustillo Antonio , Asdaghi Negar , Marulanda-londono Erika T , Gutierrez Carolina M , Samano Daniel , Sobczak Evie , Kottapally Mohan , Merenda Amedeo , Koch Sebastian , Romano Jose G , O’Phelan Kristine , Claassen Jan , Sacco Ralph L , Rundek Tatjana
Published: March 2021

Background:
Impaired level of consciousness (LOC) on presentation after intracerebral hemorrhage (ICH) may affect outcomes and the decision to withdraw life-sustaining treatment (WLST). We aim to investigate the outcomes and trends after ICH by the LOC status on presentation.

Methods:
We studied 37,613 cases with ICH in the Florida Stroke Registry from 2010-2019. Pearson chi-squared and Kruskall-Wallis tests were used to compare descriptive statistics. A multivariable-logistic regression with GEE accounted for basic demographics, comorbidities, ICH severity, hospital size and teaching status.

Results:
At stroke presentation, 12,272 (33%) cases had impaired LOC (mean age 72, 49% women, 61 white%, 20% Black, 14% Hispanic). Compared to cases with preserved LOC, LOC case were older (72 vs. 70 years old), more women (49% vs. 45%), more likely to have aphasia (38% vs. 16%), had lower GCS score (9 vs. 15), had greater ICH score (3 vs. 1), greater WLST rates (41% vs. 18%), and had greater in-hospital mortality rates (32% vs. 12%). In our adjusted model, no association was found between impaired LOC and in-hospital mortality, or length of stay. Those with preserved LOC were more likely discharged home/rehab (OR 0.4, 95%CI 0.2-0.9, p=0.03) and more likely to ambulate independently (OR 1.6, 95%CI 1.1-2.4, p=0.02). Trend analysis (2010-2019) showed decreased mortality, increased length of stay, and increased rates of discharge to home/rehab in all, regardless of the LOC status.

Conclusion:
In this large multi-center registry, a third of ICH cases presents with impaired LOC. Although LOC was not associated with significantly more in-hospital morality, LOC was associated with had higher rates of WLST and more disability at discharge. Future efforts should focus on biomarkers of LOC that detect early recovery and reduced disability in ICH patients with impaired LOC.
Abstract P440: Inpatient Blood Pressure Variability is Associated With Mortality and Poor Functional Outcome in Patients With Intracerebral Hemorrhage
Authors: Myserlis Evangelos Pavlos , Abramson Jessica R , Alabsi Haitham , Anderson Christopher D , Biffi Alessandro , Rosand Jonathan
Published: March 2021

Introduction:
Although elevated blood pressure (BP) is an established risk factor for intracerebral hemorrhage (ICH), the impact of acute BP fluctuations on ICH outcomes remains unclear. In this study, we sought to investigate the effect of acute BP variability (BPV) on mortality and functional outcome in ICH survivors.

Methods:
Subjects were consecutive ICH patients ≥ 18 years with available inpatient BP data, who survived hospitalization. Four measures of systolic BPV were calculated: standard deviation (SD), coefficient of variation (CoV), average real variability (ARV), and successive variation (SV). Our outcomes were (1) death and (2) poor functional outcome, defined as a modified Rankin Score (mRS) of 3-6 in a period between 60-120 days after discharge. We assessed the effect of hyperacute (ICH event-72 hours) and acute/subacute (72 hours-discharge) BPV on outcomes. We constructed Cox proportional hazards and logistic regression models to investigate the associations of BPV (per 10 mmHg increase) with mortality and poor functional outcome, respectively, after adjustment for potential confounders.

Results:
We included 345 patients, 120 of whom had available mRS data. 151 (43.8%) patients were female and 280 (81.2%) were white; mean age was 71 (±13) years. SBP ARV and SBP SV were the strongest predictors of mortality (HR 2.53-2.91 per 10 mmHg increase), while SBP SD, CoV, and SV were the strongest predictors of poor functional outcome (OR 2.89-5.14 per 10 mmHg increase)
(Table)
. These associations remained significant when analyzing both hyperacute as well as acute/subacute BPV. Compared to hyperacute BPV, acute/subacute BPV was more strongly associated with both mortality and poor functional outcome.

Conclusion:
Inpatient blood pressure variability is an important determinant of mortality and poor functional outcome in ICH survivors. Further studies are needed to investigate the role of addressing BPV as a potential target for intervention.
Abstract P448: Axial versus Vertical Area of Intracerebral Hemorrhage and Outcome
Authors: Ades Laura M , Sekar Padmini , Behymer Tyler P , Haverbusch Mary A , Gilkerson Lee A , Murphy Ryan , Kwon Soo Young , Van Sanford Carson D , Antzoulatos Eleni , Aziz Yasmin N , Ridha Mohamed , Flaherty Matthew L , Woo Daniel , Demel Stacie L
Published: March 2021

Background:
Intracerebral hemorrhage (ICH) has the highest morbidity and mortality rate of the major stroke subtypes. Volume is a well-established predictor of outcome. Theoretically, ICH should expand more in areas of less resistance. We hypothesize that 1) expansion perpendicular to neural tracts (axially) will be less great than expansion parallel to tracts (vertically) and 2) differing effect on outcome will occur based on axial and vertical areas of hemorrhage.

Methods:
The Genetic and Environmental Risk Factors of Hemorrhagic Stroke (GERFHS) study is a population-based case-control study. Each case of ICH within the 5 county region of Greater Cincinnati was evaluated for volume of hemorrhage with a subset completing 3 month telephone follow-up to obtain data including modified Rankin Scale (mRS). Baseline variables were assessed for poor outcome, defined as mRS greater than or equal to 3 at 90 days.

Results:
From July 2009 to December 2012, 1205 cases of ICH were identified, of which 304 had 3-month follow up. The table presents univariate association with outcome. More than 86% of hemorrhages had greater vertical area than axial area. On multivariable analysis controlling for ICH score variables, vertical area showed a trend toward worse outcome (OR 1.09, p= 0.06) vs axial area (OR 0.97, p=0.69) which was not found to have a significant effect on outcome independent of total volume.

Conclusion:
Most patients have greater vertical expansion of ICH than axial expansion. This pattern of hemorrhage growth is consistent with neural tracts having less resistance vertically. If the greater impact on outcome is confirmed, improved outcome and trial inclusion criteria may be determined.
Abstract P453: Histamine 2 Blockers and Nimodipine in Aneurysmal Subarachnoid Hemorrhage Patients
Authors: Qureshi Adnan I , Huang Wei , Lobanova Iryna , Ishfaq Fawad , Kumar Nitish , Hamid Tariq , qualls kathryn , Arora Niraj , Nattanmai Premkumar , Siddiq Farhan , Gomez Camilo r
Published: March 2021

Background:
Histamine (H) 2 blockers led to a significant increase of the relative bioavailability of nimodipine and therefore may change tolerability of nimodipine in patients with aneurysmal subarachnoid hemorrhage (SAH).

Objective:
To determine the effect of H2 blockers on outcome of SAH patients being treated with nimodipine on outcomes.

Methods:
We analyzed data from Cerner Health Facts® which collected data from participating facilities from January 1st, 2000 to July 1st, 2018. We identified SAH patients who underwent endovascular or surgical treatment for intracranial aneurysm and received nimodipine with or without H2 blockers. Outcome was defined by discharge destination and classified into none to minimal disability, moderate to severe disability, or death.

Results:
A total of 815 (54.8%) of 1488 SAH patients received H2 blockers in addition to nimodipine. There were no differences in rates of cerebral ischemia (8.8% versus 9.8%) or performance of angioplasty (3.8% versus 3.7%) between patients who did or did not receive H2 blockers. There were no differences in rates of intubation/mechanical ventilation (26.0% versus 29.3%) or intra-procedural cerebral infarction (3.4% versus 2.8%) between the two groups. There was no difference in in hospital mortality rates (10.9% versus 10.2%) or none to minimal disability (41.8% versus 38.2%) between patients who did or did not receive H2 blockers.

Conclusions:
H2 blockers are frequently used with nimodipine in SAH patients and did not appear to adversely affect rates of death or disability. The finding does not support any clinically significant interaction between H2 blockers and nimodipine in SAH patients.
Abstract P459: Inversion of T Waves on Admission is Associated With Mortality in Spontaneous Intracerebral Hemorrhage
Authors: Loggini Andrea , El Ammar Faten , Tangonan Ruth , Kramer Christopher L , Lazaridis Christos , Goldenberg Fernando D , Mansour Ali
Published: March 2021

Introduction:
Cardiac dysfunction directly caused by spontaneous intracerebral hemorrhage (ICH) is a poorly understood phenomenon, and its impact on outcome is still uncertain. Aim of this study is to investigate the relationship between electrocardiographic (EKG) abnormalities and mortality in ICH.

Methods:
This is a retrospective study analyzing EKG patterns on admission in patients admitted with ICH at a tertiary care center over eight-year period. For each patient, demographics, medical history, clinical presentation, EKG on admission and repeated during hospitalization, and head CT at presentation were reviewed. Mortality was noted.

Results:
A total of 301 ICHs were included in the study. The most prevalent EKG abnormalities were QTc prolongation in 56% of patients (n=168) followed by inversion of T waves (TWI) in 37% of patients (n=110). QTc prolongation was associated with ganglionic location (p=0.03) and intraventricular hemorrhage (IVH) (p=0.01), TWI was associated with ganglionic location (p=0.02), PR prolongation with IVH (p=0.01), while QRS prolongation was associated with lobar location (p<0.01). Volume of ICH, hemispheric laterality, and involvement of insular cortex were not correlated with specific EKG patterns. In a logistic regression model, after correcting for ICH severity and prior cardiac history, presence of TWI was independently associated with mortality (OR: 3.04, CI:1.6-5.8, p<0.01). Adding TWI to ICH score improved its prognostic accuracy (AUC 0.81). Disappearance of TWI during hospitalization did not translate in improvement of survival (p=0.5).

Conclusion:
Presence of TWI on admission is an independent and unmodifiable factor associated with mortality in ICH. TWI may be implemented as an additional early prognostic tool in clinical practice.
Abstract P46: Baseline Characteristics of Patients With Cerebral Cavernous Angiomas With Symptomatic Hemorrhage in a Multisite Trial Readiness Study
Authors: Kim Helen , Flemming Kelly , Nelson Jeffrey , Lui Avery , Majersik Jennifer J , Zabramski Joseph , Zafar Atif , Torbey Michel T , Mabray Marc , Robinson Myranda , Thompson Richard , McBee Nichol , Treine Kevin , Stadnik Agnieszka , Piedad Kristina , Hobson Nick , Shkoukani Abdallah , Carrion Penagos Julian , Mendoza-Puccini Carolina , Koenig Jim I , Hanley Daniel F , Awad Issam A
Published: March 2021

Background:
Patients with cerebral cavernous angiomas with symptomatic hemorrhage (CASH) have high risk of disability from recurrent bleeding. Candidate medications to prevent rebleeding in CASH lesions will require multisite clinical trials with standardized data collection.

Objective:
To report the prevalence and baseline cohort features in CASH patients and establish a research network infrastructure for trials.

Methods:
This prospective observational cohort study includes adults with radiologically verified CASH lesion within 1-year of consent. Exclusions include prior or planned surgical intervention, spinal location, or prior brain irradiation. Six sites enrolled patients into the screening and clinical assessment portion of the study starting July 2018. Patients also had the option to participate in the follow up biomarker validation at 4 sites. Baseline demographics, clinical and imaging information, and outcomes (mRS, PROMIS-29, NIHSS, and EuroQol-5D) were collected. Biomarker imaging included dynamic contrast enhanced quantitative perfusion (DCEQP) and quantitative susceptibility mapping (QSM) that correlated with symptomatic bleeding. Descriptive statistics were performed and one-sample t-test was used to compare whether mean T-scores for PROMIS-29 domains differed significantly from a reference population.

Results:
As of May 2020, 849 CASH patients were screened of whom 110 (13%) were eligible and enrolled; 73 also enrolled into the biomarker validation study. Average age at enrollment was 46±16 years at a mean of 4.4 months after symptom onset; 53% were female, 41% were familial, and 43% of CASH lesions were brainstem location. At enrollment, 90% of the cohort had independent functional outcome (mRS ≤ 2 and NIHSS <5). Perceived health problems affecting QoL were reported in >30% (EuroQol-5D). CASH cases had significantly worse anxiety but better depression and social satisfaction scores compared to a general population (all P<0.01). Baseline DCEQP and QSM measures did not differ significantly across sites.

Conclusion:
We demonstrate feasibility of multisite recruitment of CASH patients and report prevalence of baseline features that will aid in design of clinical trials and inclusion of appropriate outcome measures.